State of California Health and Human Services Agency ...

1 State of California Health and Human Services AgencyDepartment of Health Care ServicesStaying HealthyAssessmentAdultPatient s Name (first & last)Date of BirthFemaleMaleToday s DatePerson Completing Form (if patient needs help)Family Member Friend Other(Specify)Need help with form?Yes NoPlease answer all the questions on this form as best you can. Circle Skip if you do not know an answer or do not wish to answer. Be sure to talk to the doctor if you have questions about Need Interpreter?Yes Noanything on this form. Your answers will be protected as part of your medical Use Only:1Do you drink or eat 3 servings of calcium-rich foods daily, such asmilk, cheese, yogurt, soy milk, or tofu?

2 YesNoSkipN u t r i t i o n2Do you eat fruits and vegetables every day? YesNoSkip3Do you limit the amount of fried food or fast food that you eat? YesNoSkip4 Are you easily able to get enough healthy food?YesNoSkip5Do you drink a soda, juice drink, sports or energy drink most daysof the week?NoYesSkip6Do you often eat too much or too littlefood? NoYesSkip7 Are you concerned about your weight?NoYesSkip8Do you exercise or spend time doing activities, such as walking, gardening, swimmingfor hour a day?YesNoPhysicalActivitySkip9Do you feel safe where you live?10 Have you had any car accidents lately? YesNoNoYesSkipSkipS a f e t y11 Have you been hit, slapped, kicked, or physically hurt by someoneinthe last year?

3 NoYesSkip12Do you always wear a seat belt when driving or riding in a car?YesNoSkip13Do you keep a gun in yourhouseor place where you live? NoYesSkip1415Do you brush and floss your teeth daily?Do you often feel sad, hopeless, angry, or worried?Do you often have trouble sleeping?16 YesNoNoNoYesYesSkipSkipSkipD e n t a l H e a l t hM e n t a l H e a l t h17Do you smoke or chew tobacco?NoYesSkipA l c o h o l , T o b a c c o ,D r u g U s e18Do friends or family members smoke in your house or place where you live? NoYesSkipPage 1of 2 SHA (Adult)DHCS7098 H (Rev 12/13) State of California Health and Human Services AgencyDepartment of Health Care Services19In the past year, have you had:(men)5 or more alcoholdrinks in one day?

4 (women)4or more alcoholdrinks in oneday?NoYesSkip20Do you use any drugs or medicines to help you sleep, relax, calm down, feel better, or lose weight? NoYesSkip21Do you thinkyou or your partner could be pregnant? NoYesS e x u a l I s s u e sSkip22Do you think you or your partner could have a sexually transmitted infection(STI), such as Chlamydia, Gonorrhea, genital warts, NoYesSkip23 Have you or your partner(s) had sex without using birth control in the past year?NoYesSkip24 Have you or your partner(s) had sex with other people in the past year? NoYesSkip25 Have you or your partner(s) had sex without a condom in the past year? NoYesSkip26 Haveyou ever been forced or pressured to have sex?

5 NoYesSkip27Do you have other questions or concerns about your Health ?NoYesO t h e r Q u e s t i o n sSkipIf yes, please describe:Clinic Use OnlyCounseledReferredAnticipatory GuidanceFollow-upOrderedComments:Nutriti on Physical activity Safety Dental HealthMental Health Alcohol, Tobacco, Drug UseSexual IssuesPatientDeclined the SHAPCP s Signature:Print Name: Date:SHA ANNUAL REVIEWPCP s Signature:Print Name: Date:PCP s Signature:Print Name: Date:PCP s Signature:Print Name: Date:PCP s Signature:Print Name: Date:Page 2of 2 SHA (Adult)DHCS7098 H (Rev 12/13)