WebState of California – Health and Human Services Agency Department of Health Care Services DHCS 7098 A (Rev 12/14) SHA (0 – 6 Months) Page 1 of 2 Staying Healthy Assessment 0 – 6 Months Child’s Name (first & last) Female ... Health and Human Services Agency Department of Health Care Services . DHCS 7098 A (Rev 12/14) SHA (0 – 6 … WebState of California — Health and Human Services Agency Department of Health Care Services DHCS 7098 H (Rev 12/13) SHA (Adult) Page 2 of 2 19 In the past year, have you had: (men) No5 or more alcohol drinks in one day? (women) 4 or more alcohol drinks in one day? Yes Skip 20 Do you use any drugs or medicines to help you sleep, relax,
State of California Health and Human Services Agency
WebDHCS 7098 H (Rev 12/13) SHA (Adult) Page 1 of 2. State of California —Health and Human Services Agency Department of Health Care Services 19 In the past year, have you … WebState of California — Health and Human Services Agency Department of Health Care Services Staying Healthy Assessment 12 – 17 Years DHCS 7098 G (Rev 12/14) SHA (12 – 17 Years) Page 1 of 2 Name (first & last) Date of Birth Female Male Today’s Date Grade in School: Person Completing Form Parent Relative e46 rear seat couch
Staying Healthy Assessment
WebState of California – Health and Human Services Agency Department of Health Care Services DHCS 7098 I HMONG (Rev 12/13) SHA (Senior) Page 3 of 3 26 Koj lossis koj tus khub puas tau pw nrog lwm tus tibneeg xyoo tas los no? She/he or partner(s) had sex with other people in the past year? Tsis Tau No Tau Yes Hla Skip 27 Tau WebState of California — Health and Human Services Agency Department of Health Care Services DHCS 7098 G (Rev 12/14) SHA (12 – 17 Years) Page 1 of 2 Staying Healthy … WebState of California — Health and Human Services Agency Department of Health Care Services DHCS 7098 B (Rev 12/14) SHA (7 – 12 Months) Page 1 of 2 Staying Healthy Assessment ... State of California — Health and Human Services Agency Department of Health Care Services . DHCS 7098 B (Rev 12/14) SHA (7 – 12 Months) Page 2 of 2 . 11 . cs go cash