Form Dhcs 7098 - California Pagsusuri Upang Manatiling Malusug - Health And Human Services Agency Page 2

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State of California – Health and Human Services Agency
Department of Health Care Services
Huwag
Oo
Hindi
Sagutin
Palagi mo bang binabantayan ang iyong sanggol kung
10
siya ay nasa paliguan?
Huwag
Yes
No
Always stays with baby in the bathtub?
Skip
Oo
Hindi
Sagutin
Palagi mo bang inilalagay ang iyong sanggol sa car seat
11
sa likod na nakaharap sa pinakahuling upuan?
Yes
No
Huwag
Always places baby in a rear facing car seat in the back seat?
Oo
Hindi
Skip
Sagutin
Ang ginagamit mo bang car seat ay ang angkop para sa
12
edad at laki ng iyong sanggol?
Yes
No
Huwag
Car seat used is correct size for age and size of baby?
Skip
Hindi
Oo
Sagutin
Ang iyong sanggol ba ay nananatili sa bahay na may naka
13
tagong baril?
No
Yes
Huwag
Baby spends time in home where a gun is kept?
Skip
Hindi
Oo
Sagutin
D e n t a l H e a l t h
Maliban sa formula, gatas ng ina, o tubig, nilalagyan mo
14
pa ba ng iba ang boteng ibinibigay mo sa iyong sanggol?
No
Yes
Huwag
Gives baby a bottle with anything in it except formula, breast milk, or water?
Skip
Hindi
Oo
Sagutin
T o b a c c o E x p o s u r e
Ang iyong sanggol ba ay nakikihalo-bilo sa isang taong
15
naninigarilyo?
No
Yes
Baby spends time with anyone who smokes?
Huwag
Skip
Hindi
Oo
Sagutin
O t h e r Q u e s t i o n s
Mayroong ka pa bang ibang mga katanungan o pag-aalala
tungkol sa kalusugan, paglaki o pag-uugali ng iyong
16
No
Yes
sanggol?
Skip
Any other questions or concerns about baby’s health, development or behavior?
Kung oo, paki larawan:
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 A TAGALOG (Rev 12/14)
SHA (0 – 6 Months)
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