Form Dhcs 7098 - California Staying Healthy Assessment (Tagalog) - Health And Human Services Agency Page 3
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3State 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
26
pagtatalik sa mga ibang tao sa loob ng nakaraang taon?
No
Yes
Skip
She/he or partner(s) had sex with other people in the past year?
Huwag
Ikaw ba o ang iyong (mga) kapareha ay nagkaroon ng
Hindi
Oo
Sagutin
27
pagtatalik na walang condom sa loob ng nakaraang taon?
No
Yes
Skip
She/he or your partner(s) had sex without a condom in the past year?
Huwag
Hindi
Oo
Ikaw ba ay minsan nang pinilit o naubliga na magkaroon ng
Sagutin
28
pakikipagtalik?
No
Yes
Ever been forced or pressured to have sex?
Skip
Independent Living
Huwag
Mayroon bang tao na tutulong sa iyo para gagawa ng mga
Oo
Hindi
Sagutin
29
desisyon tungkol sa iyong kalusugan at pangangalagang
Yes
No
Skip
medikal?
Has someone to help make decisions about her/his health and medical care?)
Huwag
Ikaw ba ay nanganga-ilangan ng tulong maligo, kumain,
Hindi
Oo
Sagutin
30
maglakad, magbihis, o gumamit ng banyo?
No
Yes
Skip
Needs help bathing, eating, walking, dressing, or using the bathroom?
Huwag
Oo
Hindi
Mayroon ka bang matawagan para hingian ng tulong sa oras
Sagutin
31
ng emerhensiya?
Yes
No
Has someone to call when needs help in an emergency?
Skip
O t h e r Q u e s t i o n s
Huwag
Ikaw ba ay mayron pang ibang katanungan o mga pag-aalala
Hindi
Oo
Sagutin
32
tungkol sa iyong kalusugan?
No
Yes
Skip
Any other questions or concerns about your health?
Kung oo, paki larawan:
Anticipatory
Follow-up
Comments:
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
Independent Living
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:
PCP’s Signature:
Print Name:
Date:
DHCS 7098 I TAGALOG (Rev 12/13)
SHA (Senior)
Page 3 of 3
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