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

ADVERTISEMENT

State of California – Health and Human Services Agency
Department of Health Care Services
Huwag
Ikaw ba o ang iyong (mga) kapareha ay nagkaroon ng
Hindi
Oo
Sagutin
24
pagtatalik sa mga ibang tao sa loob ng nakaraang taon?
No
Yes
She/he or partner(s) had sex with other people in the past year?
Skip
Huwag
Ikaw ba o ang iyong (mga) kapareha ay nagkaroon ng
Hindi
Oo
Sagutin
25
pagtatalik na walang condom sa loob ng nakaraang taon?
No
Yes
She/he or partner(s) had sex without a condom in the past year?
Skip
Huwag
Ikaw ba ay minsan nang pinilit o naubliga na magkaroon ng
Hindi
Oo
Sagutin
26
pakikipagtalik?
No
Yes
Ever been forced or pressured to have sex?
Skip
Other Questions
Huwag
Ikaw ba ay mayron pang ibang katanungan o mga pag-aalala
Hindi
Oo
Sagutin
27
tungkol sa iyong kalusugan?
No
Yes
Any other questions or concerns about health?
Skip
Kung oo, paki larawan:
Comments:
Anticipatory
Follow-up
Clinic Use Only
Counseled
Referred
Guidance
Ordered
Nutrition
Physical activity
Safety
Dental Health
Mental Health
Alcohol, Tobacco, Drug Use
Sexual Issues
Patient Declined the SHA
PCP’s Signature:
Date:
Print Name:
SHA ANNUAL REVIEW
PCP’s Signature:
Date:
Print Name:
PCP’s Signature:
Date:
Print Name:
PCP’s Signature:
Date:
Print Name:
PCP’s Signature:
Date:
Print Name:
DHCS 7098 H TAGALOG (Rev 12/13)
SHA (Adult)
Page 3 of 3

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Dhcs 7098 - California Staying Healthy Assessment (tagalog) - Health And Human Services Agency Form Dhcs 7098 - California Staying Healthy Assessment (tagalog) - Health And Human Services Agency Legal
Form Dhcs 7098 - California Staying Healthy Assessment (tagalog) - Health And Human Services Agency Form Dhcs 7098 - California Staying Healthy Assessment (tagalog) - Health And Human Services Agency Legal
Form Dhcs 7098 - California Staying Healthy Assessment (spanish) - Health And Human Services Form Dhcs 7098 - California Staying Healthy Assessment (spanish) - Health And Human Services Financial
Form Dhcs 7098 - California Pagsusuri Upang Manatiling Malusug - Health And Human Services Agency Form Dhcs 7098 - California Pagsusuri Upang Manatiling Malusug - Health And Human Services Agency Legal
Form Dhcs 7013 - California Change Of Status Liens - Health And Human Services Agency Form Dhcs 7013 - California Change Of Status Liens - Health And Human Services Agency Legal
Form Dhcs 7037 - California Pickle Resource Work Sheet - Health And Human Services Agency Form Dhcs 7037 - California Pickle Resource Work Sheet - Health And Human Services Agency Legal
Form Dhcs 4087 - California Master Index Rejection Notice - Health And Human Services Agency Form Dhcs 4087 - California Master Index Rejection Notice - Health And Human Services Agency Legal
Form Dhcs 7021 - California Financial Eligibility Work Sheet - Health And Human Services Agency Form Dhcs 7021 - California Financial Eligibility Work Sheet - Health And Human Services Agency Legal
Form Dhcs 5085 - California Designation Of Administrative Responsibility - Health And Human Services Agency Form Dhcs 5085 - California Designation Of Administrative Responsibility - Health And Human Services Agency Financial
Form Dhcs 4468 - California Family Pact Provider Application - Health And Human Services Agency Form Dhcs 4468 - California Family Pact Provider Application - Health And Human Services Agency Legal

Related Categories

Parent category: Legal
Download
Go
Page of 3