CA Excel_Van Baalen

8/16/2019 CA Excel_Van Baalen

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Client's full name: Laura Van Baalen

RESOURCES FOR EXERCISE MAINTENANCE

1 = Strongly Disagree 5 = Strongly Agree

1 2 3 4 5

1 Regular physical actiity ma!es me feel "etter# 5

2 $'e neer "een a person %ho sets clear goals# &

3 y frien(s support my interests an( efforts# )

4 $ "eliee that regular physical actiity is nee(e( for goo( health# 5

5 *hen physical actiities get stressful+ $ stop them# &

6 $'m goo( at applying myself to ne% tas!s# )

7 ,hysical e-ertion is rarely en.oya"le for me# &

8 y family mem"ers support my interests an( efforts 5

&i0ht o& #&on0 ans#e&s, o"& ans#e&s #i%% $e e)t st&i(t+ (oni*entia%,


2/22

1 = Strongly Disagree 5 = Strongly Agr

1 2 3 4 5

$ can persist %hen a tas! is tiring+ uncomforta"le+ an(/or painful# &

1 $ am responsi"le for my o%n success# )

11 $ fin( it (ifficult using 0selfcontrol0 to !eep myself successful# )

12 Regular physical actiity ma!es me loo! "etter# 5

13 $ (on't li!e to oer e-ten( myself physically# &

14 $ (on't hae people aroun( %ho support my interests an( efforts# 1

15 $ aoi( physical actiity %hen $ can# &


3/22


4/22

Tota% REMS S(o&e All ,eople %ill "e %or!e( %ith regar(less of score

32

Score 2&2 R3S 1+4+&

Score ))5 R3S )+5

6his client's R3S rating is: REMS 123

Su"scales: SM AT

Selfanagement S!ills

Social Support

A"ility to 6olerate Discomfort


5/22

SEFMANA9EMENT S:IS

Re;ie# the a))&o)&iate se% mana0ement si%% han*o"t

$nitial Appointment 7oal Setting+ Dissociation &/45/41) 1 minutes spent on t

8ollo%9p 1 of 5 Relapse ,reention ,art 1

8ollo%9p 4 of 5 Relapse ,reention ,art 4

8ollo%9p & of 5 6hought Restructuring

8ollo%9p ) of 5 3-ercise 6riggers+ SelfRe%ar(

8ollo%9p 5 of 5 Reie% of All Selfanagement S!ills


6/22

his


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-ERSONA 9OA -ROFIE R3S leel: R3S 1+4+& R3S Su"scales: S

C%ient>> 6ues(ay+ April ?+ 41) 6ues(ay+ ay @+ 41) 6ues(ay+ une &+ 41) 6u

) ) ?

-EASE REMEM?ER TO ISCUSS 9ROU- EXERCISE O-TIONS

1st on0 Te&m 9oa%

Lose 45 l"s in @ months# Current %eight 15)#?

8ar from 7oal 7oal Attaine(

1 4 & ) 5 @ ? 2 1

o% far from 7oal;

Appt >


8/22

8ar from 7oal 7oal Attaine(

1 4 & ) 5 @ ? 2 1

o% far from 7oal;

Appt >


9/22


10/22


11/22

$nit ial Appointment 8ollo%9p 1 of 5 8ollo%9p 4 of 5 8ollo%9p & of 5 8ollo%9p ) of 5 8ollo%9p 5 of 5

1

4

&

)

5

@

?

2

1

1st on0 Te&m 9oa% -&o0&ess

9 o a % A ( h i e ; e m e n t


12/22

$nit ial Appointment 8ollo%9p 1 of 5 8ollo%9p 4 of 5 8ollo%9p & of 5 8ollo%9p ) of 5 8ollo%9p 5 of 5

1

4

&

)

5

@

?

2

1

2n* on0 Te&m 9oa%

9 o a % A ( h i e ; e m e n t


13/22

$nitial Appointment 8ollo%9p 1 of 5 8ollo%9p 4 of 5 8ollo%9p & of 5 8ollo%9p ) of 5 8ollo%9p 5 of 5

1

4

&

)

5

@

?

2

1

3&* on0 Te&m 9oa% -&o0&ess

9 o a % A ( h i e ; e m e n t


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-ERSONA FEEIN9S IN@ENTOR

Not at a%%1 A %itt%e

2 Mo*e&ate%+

3 B"ite a $it

4 E't&eme%+

-FI not *one on Fo%%o#U) A))t, 1 o 5

$nitial 4 of 5 & of 5 ) of 5 5 of 5

*eary 4 1

8atigue( &

*ornout 4

3-hauste( 4

6ire( & 16otal 14 4


8ull of 3nergy 1 &

Actie 4 &

3nthusiastic 4 )

Alert & )

Liely 4 )

6otal 1 1?

6his is a surey that %e %ill use to (etermine ho% your e-ercise program may "e affecting your moo( an( energyleels# Belo% are some %or(s an( phrases that (escri"e ho% people feel# ,lease fill in one response each "ase( onyour feelings oer the past t%o %ee!s+ inclu(ing to(ay# Scale is:


15/22


6ense 1 1

An-ious 1

Restless 4 4

Ferous 1

ittery 4

6otal &


16/22

1 4 & ) 5

5

1

15

4

14

4

Fati0"e

A))ointment


17/22

1 4 & ) 5

5

1

15

4

Ene&0+

A))ointment


18/22

1 4 & ) 5

5

1

15

4

St&ess

A))ointment


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?eha;io&a% Cont&a(t o&= a"&a @an ?aa%en

Starting to(ay+ 6ues(ay+ arch 45+ 41) an( continuing through the ne-t 4 %ee!s+

$ %ill %or! to reach my short term+ e-ercise an( health relate( goals+ completing & e-ercise

sessions per %ee! or a total of sessions (uring the ne-t *ee!s

M+ %on0 an* sho&t te&m 0oa%s a&e as o%%o#s=

$ hae a longterm goal to: ose >ei0ht 25 %$s 9oa% >ei0ht o 13%$s $+ Se)tem$e& 25

6he follo%ing shortterm goals %ill help me succee( at my long term goal:a Lose 4l"s "y April ?+ 41)

"

c

$ hae a longterm goal to: In(&ease Ene&0+ e;e%s

6he follo%ing shortterm goals %ill help me succee( at my long term goal:

a 6ry cycling class+ yoga

"

c

$ hae a longterm goal to:


a

"

c

$ agree to maintain this e-ercise plan until my ne-t sche(ule( appointment+ on


20/22

?eha;io&a% Cont&a(t o&=

Starting to(ay+ 6ues(ay+ ay @+ 41) an( continuing through the ne-t ) %ee!s+


sessions per %ee! or a total of 14 sessions (uring the ne-t ) %ee!s#



6he follo%ing shortterm goals %ill help me succee( at my long term goal:a 5l"s lost "y ay @#


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Starting to(ay+ 6ues(ay+ ay @+ 41) an( continuing through the ne-t ) %ee!s+


sessions per %ee! or a total of 14 sessions (uring the ne-t ) %ee!s#


$ hae a longterm goal to: ose 25 %$s in 6 months, C"&&ent #ei0ht 154,8

6he follo%ing shortterm goals %ill help me succee( at my long term goal:a Lose )l"s


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Starting to(ay+ 6ues(ay+ uly 42+ 41) an( continuing through the ne-t ? %ee!s+

$ %ill %or! to reach my short term+ e-ercise an( health relate( goals+ completing e-ercise

sessions per %ee! or a total of sessions (uring the ne-t ? %ee!s#


$ hae a longterm goal to: ose 25 %$s in 6 months, C"&&ent #ei0ht 154,8

6he follo%ing shortterm goals %ill help me succee( at my long term goal:a

"

c

$ hae a longterm goal to: In(&ease ene&0+ %e;e%s


a

"

c



a

"

c

$ agree to maintain this e-ercise plan until my ne-t sche(ule( appointment+ on

T"es*a+ Ma+ 6 214

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