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Form Dhcs 7098 - California Staying Healthy Assessment (Tagalog) - Health And Human Services Agency Page 3

State of California – Health and Human Services Agency

Department of Health Care Services

HuwagSa

Hi ndi

gutin

Sa palagaymobaikaw o angiyongkapareha ay

bakanahawaannginpeksiyongalingsapakikipagtalik (STI), tuladng

Yes

Chlamydia, Gonorrhea, genital warts, etc.?

HuwagSa

Skip

Hi ndi

Thinks she/he or partner could have a STI?

gutin

Ikawba o angiyong (mga) kapareha ay

nagkaroonngpagtataliksamgaibangtaosaloobngnakaraangtaon?

Yes

HuwagSa

She/he or partner(s) had sex with other people in the past year?

Skip

Hi ndi

gutin

Ikawba o angiyong (mga) kapareha ay

nagkaroonngpagtataliknahindigumamitngpangontrasapagbubuntis

Yes

saloobngnakaraangtaon?

HuwagSa

Skip

Hi ndi

She/he or partner(s) had sex without using birth control in the past year?

gutin

Noonghulingnagkaroonkangpakikipagtalik,

gumamitkabangpangnontrasapagbubuntis?

HuwagSa

Yes

Hi ndi

Used birth control the last time she/he had sex?

Skip

gutin

Ikawba o angiyong (mga) kapareha ay

nagkaroonngpagtataliknawalang condom saloobngnakaraangtaon?

HuwagSa

Yes

Hi ndi

She/he or partner(s) had sex without a condom in the past year?

Skip

gutin

Ikawba o angiyongkapareha ay gumamitng condom

noonghulikayongnagtalik?

Yes

HuwagSa

She/he or partner used a condom the last time they had sex?

Skip

Hi ndi

gutin

Mayroon ka bang anumang mga tanong tungkol sa iyong sekswal na

oryentasyon (kung kanino ka naaakit) o pagkakakilanlang kasarian (ano

ang pakiramdam mo bilang lalaki, babae o iba pang kasarian)?

Yes

HuwagSa

Skip

Hi ndi

Any questions about sexual orientation or gender identity?

gutin

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

Ikawba ay mayron pang ibangkatanungan o mgapag

aalalatungkolsaiyongkalusugan?

Any other questions or concerns about

Yes

health?

Skip

Comments:

Anticipatory

Follow-up

Kung oo, pakilarawan:

Counseled

Referred

Guidance

Ordered

Clinic Use Only

Nutrition

Physical activity

Safety

Dental Health

Mental Health

Alcohol, Tobacco, Drug Use

Sexual Issues

Patient Declined the SHA

PCP’s Signature:

Print Name:

Date:

PCP’s Signature:

Print Name:

Date:

SHA ANNUAL REVIEW

PCP’s Signature:

Print Name:

Date:

PCP’s Signature:

Print Name:

Date:

PCP’s Signature:

Print Name:

Date:

DHCS 7098 G TAGALOG (12/14)

SHA (12 – 17 Years)

Page 3 of 3

Form Dhcs 7098 - California Staying Healthy Assessment (Tagalog) - Health And Human Services Agency Page 3

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