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Form Dhcs 7098 B - California Staying Healthy Assessment - Health And Human Services Agency Page 2

State of California — Health and Human Services Agency

Department of Health Care Services

Yes

Skip

Do you always stay with your baby when she/he is in the

bathtub?

Yes

Skip

Do you always place your baby in a rear facing car seat in the

back seat?

Yes

Skip

Is the car seat you use the right one for the age and size of

your baby?

Yes

Skip

Does your baby spend time near a swimming pool, river, or

lake?

Yes

Skip

Does your baby spend time in a home where a gun is kept?

Yes

Skip

D e n t a l H e a l t h

Do you give your baby a bottle with anything except formula,

breast milk, or water?

Yes

Skip

T o b a c c o E x p o s u r e

Does your baby spend time with anyone who smokes?

Yes

Skip

O t h e r Q u e s t i o n s

Do you have any other questions or concerns about your

baby’s health, development or behavior?

If yes, please describe:

Follow-up

Comments:

Anticipatory

Counseled

Referred

Guidance

Ordered

Clinic Use Only

Nutrition

Physical Activity

Safety

Dental Health

Tobacco Exposure

Patient Declined the SHA

PCP’s Signature:

Print Name:

Date:

DHCS 7098 B (Rev 12/14)

SHA (7 – 12 Months)

Page 2 of 2

Form Dhcs 7098 B - California Staying Healthy Assessment - Health And Human Services Agency Page 2

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