Staying Healthy Assessment Questionnaires (SHA)

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Age and language-specific SHA questionnaires can be opened by clicking the links below. Currently all questionnaires are available in a PDF format. In the near future, the questionnaires will be available as a fillable PDF forms.

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