Self Management Goal Sheet for Prenatal Patients
Self Management Goal Sheet for Prenatal Patients
My Self Management Goal Sheet
Patient Name
Patient Name
Date
Date
Check the box of the goal or goals you want to work on now. We suggest 1-2 goals.
- Get regular dental care Get regular dental care
- Brush twice a day with fluoridated toothpaste Brush twice a day with fluoridated toothpaste
- Floss once a day AM or PM? Floss once a day AM or PM?
- Drink tap water with and in between meals Drink tap water with and in between meals
- Use a fluoridated, non-alcoholic mouth rinse Use a fluoridated, non-alcoholic mouth rinse
- Be tobacco and alcohol-free Be tobacco and alcohol-free
- Choose snacks low in sugar like nuts, dairy, fruits, and vegetables Choose snacks low in sugar like nuts, dairy, fruits, and vegetables
- Other goal for a health mouth Other goal for a health mouth
When will I do this?
When will I do this?
How often will I do this?
How often will I do this?
My confidence level that I can complete this goal
My confidence level that I can complete this goal
- 1 1
- 2 2
- 3 3
- 4 4
- 5 5
- 6 6
- 7 7
- 8 8
- 9 9
- 10 10
My Self Management Goal Sheet
Patient Name
Patient Name
Date
Date
Check the box of the goal or goals you want to work on now. We suggest 1-2 goals.
- Get regular dental care Get regular dental care
- Brush twice a day with fluoridated toothpaste Brush twice a day with fluoridated toothpaste
- Floss once a day AM or PM? Floss once a day AM or PM?
- Drink tap water with and in between meals Drink tap water with and in between meals
- Use a fluoridated, non-alcoholic mouth rinse Use a fluoridated, non-alcoholic mouth rinse
- Be tobacco and alcohol-free Be tobacco and alcohol-free
- Choose snacks low in sugar like nuts, dairy, fruits, and vegetables Choose snacks low in sugar like nuts, dairy, fruits, and vegetables
- Other goal for a health mouth Other goal for a health mouth
When will I do this?
When will I do this?
How often will I do this?
How often will I do this?
My confidence level that I can complete this goal
My confidence level that I can complete this goal
- 1 1
- 2 2
- 3 3
- 4 4
- 5 5
- 6 6
- 7 7
- 8 8
- 9 9
- 10 10
Funders & Support
Thanks to our funders for their support: Caring for Colorado Foundation; The Colorado Health Foundation; The Colorado Trust; Delta Dental of Colorado Foundation; Kaiser Permanente; Rose Community Foundation
This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS), Grant Number: H47MC28479. Information/content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.