Self Management Goal Sheet for Prenatal Patients

Self Management Goal Sheet for Prenatal Patients

My Self Management Goal Sheet

Patient Name

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?

How often will I do this?

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

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?

How often will I do this?

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

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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.