Staying Healthy Assessment

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 over 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 

Select Language: English, Spanish, Arabic, Armenian, Chinese, FarsiHmong, Khmer, Korean, Russian, SomaliTagalog, Vietnamese


7098 B    7-12 Months 

Select Language: English, Spanish, Arabic, Armenian, Chinese, FarsiHmong, Khmer, Korean, Russian, Somali, Tagalog, Vietnamese


7098 C    1-2 Years

Select Language: English, Spanish, Arabic, Armenian, Chinese, FarsiHmong, Khmer, Korean, Russian, Tagalog, Vietnamese


7098 D    3-4 Years

Select Language: English, Spanish, Arabic, Armenian, Chinese, FarsiHmong, Khmer, Korean, Russian, Tagalog, Vietnamese


7098 E    5-8 Years

Select Language: English, Spanish, Arabic, Armenian, Chinese, FarsiHmong, Khmer, Korean, Russian, Tagalog, Vietnamese


7098 F    9-11 Years

Select Language: English, Spanish, Arabic, Armenian, Chinese, FarsiHmong, Khmer, Korean, Russian, Tagalog, Vietnamese


7098 G    12-17 Years

Select Language: English, Spanish, Arabic, Armenian, Chinese, FarsiHmong, Khmer, Korean, Russian, SomaliTagalog, Vietnamese


7098 H    Adult

Select Language: English, Spanish, Arabic, Armenian, Chinese, FarsiHmong, Khmer, Korean, Russian, Tagalog, Vietnamese


7098 I    Senior 

Select Language: English, Spanish, Arabic, Armenian, Chinese, FarsiHmong, Khmer, Korean, Russian, Tagalog, Vietnamese