Specific Self Management Goals Chart
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1Patient Name:______________________________DOB _________________Chart #__________________
salmon to chart/passbook to patient
Pre-Contemplation (I’m not ready) – SMG concept discussed
but patient not ready (<7 confidence level) to establish a goal
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/ /
/ /
/ /
/ /
Date &
Date &
Date &
Date &
Specific Self Management Goals
Date SMG
Circle
Circle
Circle
Circle
Once patient sets a goal, it is recorded then discussed/scored at
subsequent visits until “4” is the normal response or goal is dropped
Set
Score
Score
Score
Score
Eat Smart (Coma bien)
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_____________________________________________________
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_____________________________________________________
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_____________________________________________________
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Get Moving (Muevase)
____________________________________________________
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____________________________________________________
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__________________________________________________
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__________________________________________________
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___________________________________________
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Health Habits/Behaviors (Hábitos de Salúd)
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_____________________________________________________
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_____________________________________________________
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_____________________________________________________
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_____________________________________________________
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1=goal set but not started
2=sometimes
3=usually
4=always/almost always
Provider to initial SMG facilitated. Any team member can review and score SMG’s, old & new, after
discussion with patient
11/02/04
This product was developed by the Advancing Diabetes Self Management program at Community Health Center, Inc. in Middletown, CT with
support from the Robert Wood Johnson Foundation® in Princeton, NJ.
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