Form Dhcs 7098 - California Staying Healthy Assessment (Tagalog) - Health And Human Services Agency

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State of California – Health and Human Services Agency
Department of Health Care Services
Pagsusuriupang
ManatilingMalusug
(Staying Healthy Assessment)
12 – 17 Taon
Pangalan (una at apelyido)
PetsangKapanganakan
KasalukuyangPe
GradosaEskuwelahan:
Babae
(12 – 17 Years)
tsa
Lalaki
AtendansiyasaEskuwel
TaongSumasagotsa Form
Magulang
Kamag-anak
Kaibigan
ahanPalagi?
Taga-Gabay
Ibang Tao (Pangalanan)
Oo
Hindi
Kailanganang
Interpreter?
Pakisagotlahatngmgakatanungansaformnaitosalahatngiyongmakakaya. Bilugan
Oo
Hindi
“HuwagSagutin” kung hindimoalamangsagot o ayawmongsumagot. Siguradohingmakipag-
usapsadoktor kung meronkangkatanungansaanumangbagaysapormangito.
Angiyongmgakasagutan ay maproprotektahanbilangbahagingiyongrekordmedikal
HuwagSa
.
Oo
Hi ndi
Clinic Use Only:
gutin
N u t r i t i o n
Umiinom o kumakainkabang 3 hainngpagkaingmayaman-sa calcium
1
saaraw-araw, katuladngagatas, keso, yogurt, gatasnagawasa soya, o
HuwagSa
Yes
No
Oo
Hi ndi
tofu?
Skip
Drinks/eats 3 servings of calcium-rich foods daily?
gutin
Kumakainkabangmgaprutas at gulaydalawangbeses man
2
HuwagSa
langsaisangaraw?
Yes
No
Eats fruits and vegetables at least 2 times per day?
Hi ndi
Oo
Skip
gutin
Kumakainkabamgapagkaingmayamansataba,
katuladngmgapritongpagkain, chips, ice cream, o pizza
3
No
Yes
masmaramingbeseskaysaisasabawatlinggo?
Skip
HuwagSa
Eats high fat foods more than once per week?
Hi ndi
Oo
gutin
Umiinomkabang mas maramikaysa 12 oz. (1 lata ng soda)
sabawatarawngjuicedrink, inuminngmganaglalaro,
4
No
Yes
inumingpampalakas, o inumingmatatamisnakape?
HuwagSa
Skip
Oo
Hi ndi
Drinks more than 12 oz. per day of juice/sports/energy drink, or sweetened coffee drink?
gutin
P h y s i c a l A c t i v i t y
Ikawba ay nag-eehersisyo o naglalarongmga sports
HuwagSa
5
Hi ndi
Oo
karamihansamgaarawnglinggo?
Yes
No
Exercises or plays sports most days of the week?
gutin
Skip
HuwagSa
6
Problemamobangayonangiyongtimbang?
Concerned about weight?
Oo
Hi ndi
No
Yes
gutin
Skip
Nanunuodkabang TV o naglalarong video games masmaliitkaysa 2
HuwagSa
7
Oo
Hi ndi
orassabawataraw?
Yes
No
Watches TV or plays video games less than 2 hours per day?
gutin
Skip
S a f e t y
Angbahaymoba ay mayroonggumaganangdetektorngusok?
8
HuwagSa
Yes
No
Home has working smoke detector?
Oo
Hi ndi
Skip
gutin
Angiyongbahayba ay mayroongnumerongteleponong Poison
9
Control Center (800-222-1222) nanaisulatsaiyongtelepono?
HuwagSa
No
Yes)
Oo
Hi ndi
Home has phone # of the Poison Control Center posted by phone?
Skip
gutin
Palagika bang gumagamitng seat bealt kung ikaw ay
HuwagSa
10
Hi ndi
Oo
nagmamanehongkotse?
Yes
No
Always wears a seatbelt when riding in a car?
gutin
Skip
Nagpapalipaskabasabahayna may nakatagongbaril?
11
Spends time in a home where a gun is kept?
No
Yes
Skip
DHCS 7098 G TAGALOG (12/14)
SHA (12 – 17 Years)
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