Personal Health Promotion & Wellness Plan

Student: ______________________________    Date: _____________



Complete your Health Promotion & Wellness Plan using the form provided. This form has 4 pages-use 1 page per topic/goal.


The Nursing Program has a zero tolerance for late assignments; therefore, no late assignments will be accepted in any course. Any assignment not submitted before the stated deadline will receive a zero.  

Google Chrome is the browser for use with the D2L Learning Management system.  Submitted assignments must be completed as a Microsoft word (.doc or docx) file. Please double check your attachments and formatting when submitting. NO CREDIT WILL BE GIVEN FOR INCORRECTLY FORMATTED ASSIGNMENTS.


  1. You must have at least 4 holistic topics/categories which must include a Financial topic (they CANNOT be duplicated like weight loss, diet, exercise!). Each one must be unique with appropriate terminology for these topics. Holistic equals physiologic, psychosocial, spiritual, educational, etc. (examples: physiological-weight loss, exercise, control blood pressure; financial-save money, pay off credit card, educational-complete ADN program, complete BSN; spiritual-church visits weekly, daily devotions, meditation; psychosocial-mindfulness, stress management, personal relationships)
  2. Each topic must have at least 1 specific and measurable short term OR long-term goal. Mention if each goal is short term or long term in brackets. For long term goals must mention, how often you would evaluate status of the goal (i.e., at the end of the semester, once per month, etc.).
  3. You must list a minimum of 3 actions that you will perform to help you meet each of your goal. Be detailed and specific with your actions and they must be appropriate for your stated goal( example: set alarm Sunday morning to get to church on time, transfer $30 each week to savings account, limit eating out to once a week…)
  4. Under resources list all items you will use in your actions to help you meet the goal; i.e., jogging trail, gym, textbooks, church, family, grocery store, app, etc. Minimum of three resources for each goal.
  5. Must mention time to initiate each action and evaluate the goal When will you start? First of next month? Evaluate end of semester-May 15, 22….)
  6. All goals must be For example, financial goal must be:
  • Specific: state exactly what you wish to buy/accomplish with the money you save.
  • Measurable: indicate the exact dollar amount you need to accomplish your goal.
  • Attainable: identify the steps necessary to reach your goal.
  • Relevant: the goal must be meaningful, or you may lose motivation to stick with your plan.
  • Time-bound: by when do you want to meet your goal?












Grading Criteria


CRITERIA Possible Points Earned Points
Minimum of 4 holistic topics clearly stated with appropriate terminology, not duplicated (1 *4) 4  
Minimum of 1 short or long-term goal for each holistic topic. Mention in brackets either it is short term or long term (1*4) 4  
At least 3 actions identified for each goal (1*4) 4  
Goals are specific, measurable, attainable, relevant, realistic, and time bound

(Each goal takes 6 points *4)

Actions are specific & appropriate for each goal, descriptive with details of the activity and not duplicated.

(Each action takes 3 points * 12)

Time frame to initiate action and evaluate/ accomplish each goal (3points* 4) 12  
Appropriate resources identified (at least 3 resources for each goal)

(Each goal takes 3 points* 4)

Grading criteria form submitted 4  
                                                        Total 100  









Name: ___________________________________________


Student Health Promotion and Wellness Plan


Holistic Category Goal Actions Required                             (Time duration, Frequency etc) Date Actions to be Initiated Date Goal to be               Evaluated/ Accomplished Available Resources






























Holistic Category Goal Actions Required  


Date Actions to be Initiated Date Goal to

be Evaluated /Accomplished

Available Resources


































Holistic Category Goal Actions Required with details


Date Actions to be Initiated Date Goal to be Accomplished/ Evaluated Available Resources


































Holistic Category Goal Actions Required with details       Date Actions to be Initiated Date Goal to be Evaluated or Accomplished Available Resources



























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