Modification Commitment and Log
My Modification Commitment
I hereby commit to, and accept responsibility for, achieving the goals that I have initialed below. In addition, they demonstrate my motivation, confidence and commitment to the moderate my use. I understand that a slip does not give me permission to return to my old pattern of drinking, and I acknowledge that it is in my best interest not to exceed 3 drinks.
- I have completed 30 days of abstinence to first reduce my tolerance.
- I will not drink in my home, any drinking must take place at __________________
- I will spend as much time as possible in areas where drinking is prohibited.
- I will avoid places where there are temptations to drink, such as bars and time with friends who drink.
- I will not meet a friend to drink if I know it is a situation in which I will exceed my goal.
- I will drink an extra two-four glasses of water each day.
- I will throw away all of my personal alcohol.
- I will not exceed a two drink limit to begin with and I will drink water or another beverage in between drinks to help space and sip.
- I will change my drink to something I don’t care for to make it less inviting.
- I will keep a daily record of my drinking.
- I will reduce my drinking from __________ drinks and no more than __________ a week.
- I will begin or increase my physical activities to __________________ times per week.
- I will make an appointment with the University Health Services (574- 631-7497) or primary care physician for a physical health examination, and explore medical options to aid my moderation.
- I will make an appointment with the university nutritionist or local nutritionist.
- I will reward myself for accomplishing these goals by: ____________________
Signature:______________________ Date:__________________
Drink Log for Modification
Week 1
Day | Number of Drinks | Comments |
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Sun | # | Comments: |
Mon | # | Comments: |
Tues | # | Comments: |
Wed | # | Comments: |
Thurs | # | Comments: |
Fri | # | Comments: |
Sat | # | Comments: |
Week 2
Day | Number of Drinks | Comments |
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Sun | # | Comments: |
Mon | # | Comments: |
Tues | # | Comments: |
Wed | # | Comments: |
Thurs | # | Comments: |
Fri | # | Comments: |
Sat | # | Comments: |
Week 3
Day | Number of Drinks | Comments |
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Sun | # | Comments: |
Mon | # | Comments: |
Tues | # | Comments: |
Wed | # | Comments: |
Thurs | # | Comments: |
Fri | # | Comments: |
Sat | # | Comments: |
Week 4
Day | Number of Drinks | Comments |
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Sun | # | Comments: |
Mon | # | Comments: |
Tues | # | Comments: |
Wed | # | Comments: |
Thurs | # | Comments: |
Fri | # | Comments: |
Sat | # | Comments: |