Provider Forms

“Staying Healthy” Individual Health Education Behavioral Assessment Tool

The Staying Healthy Assessment (SHA) is the Department of Health Care Services’ (DHCS’s) Individual Health Education Behavior Assessment (IHEBA). The SHA was updated in June 2013 in collaboration with Medi-Cal managed care plans (Plans). The SHA consists of seven age-specific pediatric questionnaires and two adult questionnaires. It is available in all Medi-Cal threshold languages. Plan providers are required to use and administer the SHA to all Medi-Cal beneficiaries as part of the Initial Health Assessment (IHA) and periodically re-administer it according to contract requirements. Plans may use an alternative IHEBA with prior approval of the Medi-Cal Managed Care Division (MMCD).

Instructions for providers
PowerPoint training for providers
Staying Healthy Assessment Forms
Staying Healthy Assessment FAQs

CA Department of Health Care Services (DHCS) has published updated SHA forms that can be completed electronically. DHCS has not yet added these forms to their website, but you may access them by using the PDF files listed below. You may continue to use the original SHA forms if you wish, but now have the option of using the electronic forms. You may contact Jackie Hagg, RN, MSN, LNC, Facility Site Review Nurse at 1(415) 615-5637 or contact us safely and securely through our online portal at sfhp.org/contact-us with any questions or concerns. Never send any personal health information through regular email.

Staying Healthy Assessment: 0-6 Months
English :: Spanish :: Chinese :: Vietnamese :: Russian

Staying Healthy Assessment: 7-12 Months
English :: Spanish :: Chinese :: Vietnamese :: Russian

Staying Healthy Assessment: 1-2 Years
English :: Spanish :: Chinese :: Vietnamese :: Russian

Staying Healthy Assessment: 3-4 Years
English :: Spanish :: Chinese :: Vietnamese :: Russian

Staying Healthy Assessment: 5-8 Years
English :: Spanish :: Chinese :: Vietnamese :: Russian

Staying Healthy Assessment: 9-11 Years
English :: Spanish :: Chinese :: Vietnamese :: Russian

Staying Healthy Assessment: 12-17 Years
English :: Spanish :: Chinese :: Vietnamese :: Russian

Staying Healthy Assessment: Adult
English :: Spanish :: Chinese :: Vietnamese :: Russian

Staying Healthy Assessment: Senior
English :: Spanish :: Chinese :: Vietnamese :: Russian