Staying Healthy Assessment (SHA) Questionnaires

PCPs are responsible for assuring the Staying Healthy Assessment (SHA) Questionnaire is administered during the Initial Health Assessment to each IEHP Member within 120 days of the Member's enrollment. The SHA Questionnaire is available in nine different languages and in nine separate age categories.

Printed English and Spanish versions are available through your IPA or you can get the forms you need by using the menu below. You will need Adobe Acrobat Reader 4 or later to view the PDF files. You can download a free copy by clicking here.


7098 A | 0-6 Months


7098 B | 7-12 Months        


7098 C | 1-2 Years


7098 D| 3-4 Years    


7098 E | 5-8 Years      


7098 F | 9-11 Years


7098 G | 12-17 Years


7098 H | Adult


7098 I | Senior