EXERCISE  PLAN

1 MY REASONS
� I have high blood pressure, and want better control on fewer medicines.
� I have diabetes and don't want to take insulin.
� I have high blood sugars and don't want to develop "full blown diabetes".
� I have a family history and want to minimize my chances of developing problems.
� I want to lower my risk of developing heart disease or having a stroke.
� I want to minimize my chances of developing arthritis or similar problems.
� I want to look better.
� I want to feel better.
� I feel my social or job status will improve.
� Please list your own personal reasons:

2  WHAT  I  ENJOY  DOING

�  Walking                    �  Jogging                    �  Bicycling                    �  Swimming
�  Tennis                      �  Racquetball                �  Handball                   �  Basketball
� Volleyball                  � Weight Lifting            � Other

3  HOW MUCH TIME CAN YOU DEVOTE TO YOUR PROGRAM

____ minutes a day, ____ days each week

4  OTHER  FACTORS

�  I enjoy exercising with a partner
�  I enjoy exercising in a group situation
�  I would like to join a health club or have a personal trainer.
�  I have a treadmill at home
�  I have an exercise bike or other equipment at home
�  I have a mall or other indoor facility available nearby for walking, particularly in inclement weather.
�  I have a swimming pool available at home or in my area

5  THE FOLLOWING MAKES A  PROGRAM  MORE DIFFICULT

�  I have difficulty traveling to places to exercise
�  I have financial limitations in regards to health clubs, home treadmills, etc.
�  I live in a rural area, and traveling to a facility is difficult
�  Physical limitations (please explain):