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Form Dhcs 7098 B - California Staying Healthy Assessment - Health And Human Services Agency

State of California — Health and Human Services Agency

Department of Health Care Services

Staying Healthy

Assessment

7 – 12 Months

Child’s Name (first & last)

Date of Birth

Today’s Date

In Child/Day Care?

Female

Yes

Male

Person Completing Form

Need Help with Form?

Parent

Relative

Friend

Guardian

Yes

Other (Specify)

Need Interpreter?

Yes

Please answer all the questions on this form as best you can. Circle “Skip” if you do not know an

answer or do not wish to answer. Be sure to talk to the doctor if you have questions about

anything on this form. Your answers will be protected as part of your medical record.

Clinic Use Only:

Yes

Skip

N u t r i t i o n

Do you breastfeed your baby?

Yes

Skip

Does your baby drink or eat 3 servings of calcium-rich foods

daily, such as formula, breast milk, cheese, yogurt, soy milk,

or tofu?

Yes

Skip

P h ys i c a l Ac t i v i t y

Are you concerned about your baby’s weight?

Yes

Skip

Does your baby watch any TV?

Yes

Skip

S a f e t y

Does your home have a working smoke detector?

Yes

Skip

Have you turned your water temperature down to low-warm

(less than 120 degrees)?

Yes

Skip

If your home has more than one floor, do you have safety

guards on the windows and gates for the stairs?

Yes

Skip

Does your home have cleaning supplies, medicines, and

matches locked away?

Yes

Skip

Does your home have the phone number of the Poison

Control Center (800-222-1222) posted by your phone?

Yes

Skip

Do you always put your baby to sleep on her/his back?

DHCS 7098 B (Rev 12/14)

SHA (7 – 12 Months)

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Form Dhcs 7098 B - California Staying Healthy Assessment - Health And Human Services Agency

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