| DATE: | ________ | MODERATION LIMITS: | ___________________________________ |
| WEEK NUMBER: | ________ | MAIN GOAL FOR CHANGE THIS WEEK: | ___________________________________ |
| DAY of WEEK |
NUMBER of DRINKS |
NUMBER of HOURS |
BAC from TABLES |
OVER LIMITS "X" |
DESCRIBE OCCASION |
SMALL STEPS TOWARD POSITIVE LIFESTYLE CHANGES |
LIFESTYLE GOALS "Y" / "N" |
MONDAY |
- - - - - - - - - - - - | - - - - | |||||
TUESDAY |
- - - - - - - - - - - - | - - - - | |||||
WEDNESDAY |
- - - - - - - - - - - - | - - - - | |||||
THURSDAY |
- - - - - - - - - - - - | - - - - | |||||
FRIDAY |
- - - - - - - - - - - - | - - - - | |||||
SATURDAY |
- - - - - - - - - - - - | - - - - | |||||
SUNDAY |
- - - - - - - - - - - - | - - - - | |||||
| TOTALS | ////// | NUMBER of DAYS: _________ |
/////////////// | Y = _____ N = _____ |
Note: Best viewed with Netscape. This table was originally designed to be printed horizontally on standard size paper, with a table width of 9 inches. A minimum of 7 and 1/4 inches of table width is required.