Age and language-specific Staying Health Assessment (SHA) questionnaires can be opened by clicking the links below. Currently all questionnaires are available in a PDF format.

Please note: Farsi, and Khmer age-specific SHA questionnaires are available upon request. Please contact the health plan you contract with for copies.

• DHCS 7098 A (12/14) – Staying Healthy Assessment: 0-6 Months
  Alt: Arabic, Armenian, Chinese, Hmong, Korean, Russian, Spanish, Tagalog, Vietnamese
  
  
• DHCS 7098 B (12/14) – Staying Healthy Assessment: 7-12 Months
  Alt: Arabic, Armenian, Chinese, Hmong, Korean, Russian, Spanish, Tagalog, Vietnamese
  
  
• DHCS 7098 C (12/13) – Staying Healthy Assessment: 1-2 Years
  Alt: Arabic, Armenian, Chinese, Hmong, Korean, Russian, Spanish, Tagalog, Vietnamese
  
  
• DHCS 7098 D (12/13) – Staying Healthy Assessment: 3-4 Years
  Alt: Arabic, Armenian, Chinese, Hmong, Korean, Russian, Spanish, Tagalog, Vietnamese
  
  
• DHCS 7098 E (12/13) – Staying Healthy Assessment: 5-8 Years
  Alt: Arabic, Armenian, Chinese, Hmong, Korean, Russian, Spanish, Tagalog, Vietnamese
  
  
• DHCS 7098 F (12/13) – Staying Healthy Assessment: 9-11 Years
  Alt: Arabic, Armenian, Chinese, Hmong, Korean, Russian, Spanish, Tagalog, Vietnamese
  
  
• DHCS 7098 G (12/14) – Staying Healthy Assessment: 12-17 Years
  Alt: Arabic, Armenian, Chinese, Hmong, Korean, Russian, Spanish, Tagalog, Vietnamese
  
  
• DHCS 7098 H (12/13) – Staying Healthy Assessment: Adult
  Alt: Arabic, Armenian, Chinese, Hmong, Korean, Russian, Spanish, Tagalog, Vietnamese
  
  
• DHCS 7098 I (12/13) – Staying Healthy Assessment: Senior
  Alt: Arabic, Armenian, Chinese, Hmong, Korean, Russian, Spanish, Tagalog, Vietnamese