WebState of California — Health and Human Services Agency Department of Health Care Services Staying Healthy Assessment 12 – 17 Years DHCS 7098 G (Rev 12/14) SHA (12 – 17 Years) Page 1 of 2 Name (first & last) Date of Birth Female Male Today’s Date Grade in School: Person Completing Form Parent Relative WebDHCS 7098 A - Staying Healthy Assessment 0-6 Months (SHA 0-6 Months) DHCS 7098 B - Staying Healthy Assessment 7-12 Months (SHA 7-12 Months) ... CADDRA Teacher Assessment Form Available in English, French (Canada) Conners 4 * Goals for Change . Goals Questionnaire . Medication Questionnaire . Medication Side Effects (Parent)

State of California — Health and Human Services …

WebDepartment of Health Care Services SOLICITUD DE BENEFICIOS DE EVERY ... WebState of California – Health and Human Services Agency Department of Health Care Services DHCS 7098 A (Rev 12/13) SHA (0 – 6 Months) Page 1 of 2 Staying Healthy Assessment 0 – 6 Months Child’s Name (first & last) Date of Birth Female Male Yes Today’s Date In Child/Day Care? No Person Completing Form Other chiropractievergoeding.nl

State of California Health and Human Services Agency …

WebState of California — Health and Human Services Agency Department of Health Care Services DHCS 7098 F (Rev 12/13) SHA (9 – 11 Years) Page 2 of 2 . 16 . Has your child ever witnessed or been a victim of abuse or violence? No Yes Skip. 17 . Has your child been hit or has your child hit someone in the past year? No Yes Skip. 18 No WebState of California – Health and Human Services Agency Department of Health Care Services DHCS 7098 I VIETNAMESE (Rev 12/13) SHA (Senior) Page 1 of 3 (Staying Healthy Assessment) (Senior) Tên Bệnh Nhân Ngày Sinh Nữ Nam Hôm Nay Ngày b ệnh nhân Có Không ệ Có Không Clinic Use Only: 1 http://www.sfhp.org/wp-content/files/providers/forms/DHCS%207098%20I%20ENGLISH_SHA_Senior%2012.13_Writable.pdf graphics card hdmi splitter