Staying Healthy Assessment Forms for All Years

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The Staying Healthy Assessment (SHA) focuses on individual Health Education and Behavior Assessment (IHEBA).

The essence of this assessment is geared towards opening a communication line between members and their primary care provider, which is targeted at health education and counseling that changes unhealthy behavior.

This article is your best bet at learning about the staying healthy assessment, as well as all you need to know about it.

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Staying Healthy Assessment

The Staying Healthy Assessment (SHA) is a requirement of the Department of Health Care Services that includes questionnaires for all Medi-Cal recipients as part of their Initial Health Assessment (IHA).

This assessment aims to open up a line of communication between the member and their primary care provider (PCP), providing targeted health education and counseling that changes unhealthy behavior.

The Stay Health Assessment was created in the late 1990s and was updated in June 2013 in partnership with Medi-Cal managed care programs (Plans).

The Staying Health Assessment comprises seven age-specific pediatric questions and two adult questionnaires.

It is accessible in English as well as all Medi-Cal threshold languages (Arabic, Armenian, Chinese, Farsi, Hmong, Khmer, Korean, Russian, Spanish, Tagalog, and Vietnamese).

A Medi-Cal Managed Care Health Plan can provide you with Farsi and Khmer upon request.

Plan providers are expected to utilize and administer the Staying Health Assessment to all Medi-Cal clients as part of the Initial Health Assessment (IHA) and to re-administer it on a regular basis in accordance with contract requirements.

Plans may employ an alternate IHEBA with prior clearance from the Managed Care Quality and Monitoring Division (MCQMD).

A Staying Health Assessment advisory council comprised of Plan representatives and providers, as well as MCQMD employees, will be in charge of overseeing periodic changes to the questionnaires and other Staying Health Assessment tools.

Those interested in joining the Staying Health Assessment committee may make a request to the MCQMD’s health education mailbox address.

Questions, comments, and ideas about the Staying Health Assessment surveys and other materials should be sent to the following address:

Get to email them at:

Staying Health Assessment Resources:

Stay Healthy Assessment FAQs (PDF)

Behavioral Risk Topics At-A-Glance (PDF)

Adult Questions by Age Group (PDF)

Pediatric Questions by Age Group (PDF)

Provider Office Instruction Sheet (PDF)

Provider Training (PowerPoint, 7MB)

If the slide show begins when you open the PowerPoint file, select “slide show” and then “from the beginning” to begin the narrated instruction.

Staying Healthy Assessment Forms

The Staying Healthy Assessment Forms may be downloaded from one of the following websites:

Tap on the link below, and it will take you directly to where you can have access: Staying Healthy Assessment Forms.

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Staying Healthy Assessment Questionnaire

Age and language-specific SHA questionnaires can be opened by clicking the links below. Currently, all questionnaires are available in PDF format.

Please note: Farsi and Khmer age-specific SHA questionnaires are available upon request. Please contact the health plan you contract with for copies.

Alt: ArabicArmenianChineseHmongKoreanRussianSpanishTagalogVietnamese

Interpreted: ArabicArmenianChineseHmongKoreanRussianSpanishTagalogVietnamese

Interpreted: ArabicArmenianChineseHmongKoreanRussianSpanishTagalogVietnamese

Alt: ArabicArmenianChineseHmongKoreanRussianSpanishTagalogVietnamese

Interpreted: ArabicArmenianChineseHmongKoreanRussianSpanishTagalogVietnamese

Alt: ArabicArmenianChineseHmongKoreanRussianSpanishTagalogVietnamese

Interpreted: ArabicArmenianChineseHmongKoreanRussianSpanishTagalogVietnamese

Alt: ArabicArmenianChineseHmongKoreanRussianSpanishTagalogVietnamese

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How Do I Administer and Document the SHA?

  1. The SHA comprises two adult questions and seven pediatric questionnaires that are age-specific.
  • 0-6 months, 7-12 months, 1-2 years, 3-4 years, 5-8 years, 9-11 years, 12-17 years
  • Adult (18-55 years) and Senior (55+, at provider’s discretion)

2. Filling out the SHA:

  • At each new age interval, administer a fresh SHA; at yearly visits, evaluate and sign the current form.
  • Encourage patients ages 12 and older to self-complete the SHA
  • SHA questions may be asked verbally, and responses recorded directly in the patient’s EMR
  • Patients have the option of refusing, declining, or skipping any or all sections of the SHA
  • Encourage each patient to complete an age-appropriate SHA every subsequent year during a scheduled exam

3. Reviewing the completed SHA with the patient:

  • Determine the extent of risk factors on the patient’s health, and prioritize the risk factors with the patient
  • Provide tailored health education counseling, intervention, referral, follow-up, and risk reduction
  • Plan, if applicable
  • Other clinic staff may assist with reviewing the SHA with the patient as long as medical issues are referred to PCP

4. Provider’s documentation requirements:

  • Sign and print the provider’s name and date
  • Document specific behavioral risk topics and patient counseling, referrals, anticipatory guidance,
  • Document the patient’s refusal to complete the SHA
  • Keep the signed SHA in the patient’s medical record


Where are the SHA forms located?

All SHA forms and training slides are available for download and printing on the DHCS site:

What if I have additional questions?

What is the Health Assessment Questionnaire?

The Health Evaluation Questionnaire (HAQ), developed in 1980, was one of the first PRO tools to reflect a patient-oriented outcome assessment approach.

The HAQ is built on five patient-centered dimensions: disability, pain, pharmaceutical effects, care costs, and death.

What is a health assessment form?

A health assessment form is a questionnaire that helps medical and healthcare practitioners to collect information about individuals.

What questions are asked in a health assessment?

“What has brought you here today?” When did it begin and how long has it been ongoing? Is this a new problem or the first time you’ve encountered it? Is it intermittent or continuous? What makes matters worse? Do you have any additional symptoms?


The Staying Healthy Assessment (SHA) is the Department of Health Care Services (DHCS’s) version of the Individual Health Education Behavior Assessment (IHEBA). 

I hope this article was helpful, we await your comments…



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