Wellness Challenge Logs (Employee) - Nutrition & Physical Activity / Lifestyle Tracker

Form Approved
OMB No. 0920-XXXX
Exp. Date:: XX-XX--XXXX

Nutrition and Physical Activity Tracking Log
Public reporting of this collection of information is estimated to average 30 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond
to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to
CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).
Informed Consent
Before you get started, we’d like need to give you some more information to help you decide whether or not you would like
to participate.
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This project is funded by the Centers for Disease Control and Prevention. Many parts of the project are being
managed by Viridian Health Management (Viridian). Viridian is a private health and wellness company based in
Phoenix, AZ. Viridian provides flexible, customized solutions to building comprehensive healthy worksite programs.
They are helping CDC implement the National Healthy Worksite (NHW) program.
You were asked to participate because your worksite is participating in the National Healthy Worksite (NHW)
program as a benefit to employees. All employees at your worksite will be asked to complete this log during an
eight week physical activity and/or nutrition program.
Your participation in this discussion is voluntary. In the course of this log, you may refuse to answer specific
questions. You may also choose to end the discussion at any time.
The survey is designed to take about 30 minutes.
There are no right or wrong answers or ideas—we want to hear about YOUR experiences and opinions.
All of the comments you provide will be maintained in a secure manner. We will not disclose your responses or
anything about you unless we are compelled by law. Your responses will be combined with other information we
receive and reported in the aggregate as feedback from the group. In our project reports, your name will not be
linked to the comments you provide in this discussion.
CDC is authorized to collect information for this project under the Public Health Services Act.
There are no personal risks or personal benefits to you for participating in this discussion.
We are interested in your comments so that we can improve the NHW program for future participants. Please feel
free to contact [INSERT WORKSITE NHWP PROGRAM MANAGER]. [HIS/HER] number is [INSERT TEL #]. You
can also call Viridian Health Management toll-free at 1-877-486-0140.

Instructions
To make sure that health-related information and programs are tailored to affect your health problems and concerns, we
are asking each employee participating in health coaching for physical activity and nutrition to fill out this log.
Please bring the log with you to your health coaching sessions. Once completed, you can give it to [INSERT WORKSITE
NHWP HEALTH COACH]. If you have any questions, Please feel free to contact [INSERT WORKSITE NHWP HEALTH
COACH]. [HIS/HER] number is [INSERT TEL #].
Thank you very much for your participation.

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Form Approved
OMB No. 0920-XXXX
Exp. Date:: XX-XX--XXXX
Nutrition and Physical Activity Tracking Log
Week # (labeled 1 through 8)
NUTRITION

MON

TUE

WED

THU

FRI

SAT

SUN

PHYSICAL ACTIVITY

MON

TUE

WED

THU

FRI

SAT

SUN

Pedometer Steps

______

______

______

______

______

______

______

______

______

______

______

______

______

______

Vegetables
1 block = ½ cup

Fruits
1 block = ½ cup

Grains
1 block = ½ cup

Soy/Beans/Peas
1 block = ½ cup

Beef/Poultry/Pork
1 block = 3 oz

Fish / Seafood
1 block = 3 oz

Full Fat Dairy
1 block = ½ cup

Low Fat Dairy
1 block = ½ cup

Whole Eggs
1 block = 1 egg

Egg Whites
1 block = ½ cup

Water
1 block = 8 oz.

Minutes
Exercised
Breathing
Intensity During
Walks or Exercise
1.

2.
3.
4.

Easy
Moderate
Heavy

Easy
Moderate
Heavy

Easy
Moderate
Heavy

Easy
Moderate
Heavy

Easy
Moderate
Heavy

Easy
Moderate
Heavy

Easy
Moderate
Heavy

Portion sizes:
a. A ½ cup serving is about the same as ½ of a baseball.
b. A 3 ounce (oz.) serving as about the size of a deck of cards.
Full Fat Dairy includes whole and reduced fat (2%) milk, cheese, yogurt and other dairy products.
Reduced Fat Dairy includes no fat (skim) and low fat (1%) milk, cheese, yogurt and other dairy products.
Description of Breathing Intensity During Walks or Exercise: "Easy” = you could sing a song; “Moderate” = you could carry
on a conversation; “Heavy” = you could only speak a few words at a time.

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Lifestyle Tracker

Form Approved
OMB No. 0920-XXXX
Exp. Date:: XX-XX--XXXX

MONTH: ___________________ NAME: ______________________________
My Weigh Start of Month: _____________ My Weight End of Month: _____________
Instructions: Each day, write your activities and the number of minutes per activity. Also, circle the number of portions of Fruits and Vegetables you eat, the number of
glasses of Water (8 oz.) you drink, and the number of portions of High Fat foods you eat on the form below (F=Fruits; V=Vegetables; W=Water, HF – High Fat Foods)

Monday - date_____ Tuesday
Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8

Wednesday

Thursday

Friday

Saturday

Sunday

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8.

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8

Monday - date_____ Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8
.

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–
HF: 1–2–3–4–5–6–7–8
.

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8
.

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8
.

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8
.

Wednesday

Thursday

Friday

Saturday

Sunday

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8
.

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8
.

Monday - date_____ Tuesday
Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8

Monday - date_____ Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8
.

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8
.

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8
.

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8
.

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8
.

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8
.

Activity
Minutes
_____________#_____
_____________#_____
F: 1–2–3–4–5
V: 1–2–3–4–5
W: 1–2–3–4–5–6–7–8
HF: 1–2–3–4–5–6–7–8
.

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