Nutrition and Physical Activity Tracker Log / Health 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.

• 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 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 voluntarily 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 to consider voluntarily filling out this log for physical activity and nutrition .

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 chose to. 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.

Nutrition and Physical Activity Tracking Log

Week # (labeled 1 through 8)

NUTRITION	MON	TUE	WED	THU	FRI	SAT	SUN
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.	 	 	 	 	 	 	 
PHYSICAL ACTIVITY	MON	TUE	WED	THU	FRI	SAT	SUN
Pedometer Steps							
Minutes Exercised							
Breathing Intensity During Walks or Exercise	Easy Moderate Heavy	Easy Moderate Heavy	Easy Moderate Heavy	Easy Moderate Heavy	Easy Moderate Heavy	Easy Moderate Heavy	Easy Moderate Heavy

1. Portion sizes:

   1. A ½ cup serving is about the same as ½ of a baseball.

   2. A 3 ounce (oz.) serving as about the size of a deck of cards.

2. Full Fat Dairy includes whole and reduced fat (2%) milk, cheese, yogurt and other dairy products.

3. Reduced Fat Dairy includes no fat (skim) and low fat (1%) milk, cheese, yogurt and other dairy products.

4. 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.

Health Tracker

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	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
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– 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 .
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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