Free HealthCheck Individual Health History (Hmong), HCF 1002H - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1002H (07/08)

STATE OF WISCONSIN

TSHUAJ KEV MOB KEEB KWM KEV MOB NKEEG
HEALTHCHECK INDIVIDUAL HEALTH HISTORY (Hmong)
Kev Pab Kho Mob Medical Assistance tus I.D. Number Tam Sim No Per Code

Ua ib daim foos rau txhua tus neeg tshuaj kev mob nkeeg Fill out one form for each person screened
Npe ­ Tus Neeg Mob Chaw Nyob ­ Tus Neeg Mob Xov Tooj ­ Tus Neeg Mob Hnub Yug ­ Tus Neeg Mob (Hli/Hnub/Xyoo)

Hnub Ua Daim Foos No (Hli/Hnub /Xyoo)

Npe ­ Niam thiab Txiv los yog Tus Saib Xyuas Chaw Nyob ­ Niam thiab Txiv los yog Tus Saib Xyuas Xov Tooj ­ Niam thiab Txiv los yog Tus Saib Xyuas

Tsev Kawm Ntawv thiab Qib Kawm los yog Txoj Hauj Lwm ­ Tus Neeg Mob

Npe thiab Chaw Nyob ­ Tus Kws Kho Mob Npe thiab Chaw Nyob ­ Tus Kws Kho Hniav

KEV MOB NKEEG ­ Teb rau Txhua Tus Tsis Hais Hnub Nyoog Li Cas
GENERAL HEALTH - Answer for All Ages
Office Use Yog (Yes) 1 2 3 4 5 Tsis Yog (No) Tsis Paub (Don't Know) Nws puas yog ntau tshaj 12 lub hlis lawm txij thaum tus neeg no tau mus tshuaj mob (checkup) nrog ib tus kws kho mob? Nws puas yog ntau tshaj 12 lub hlis lawm txij thaum ib tus kws kho mob tau tshuaj tus neeg no vim muaj mob los yog raug mob? Nws puas yog ntau tshaj 12 lub hlis lawm txij thaum tus neeg no tau mus tshuaj mob (checkup) nrog ib tus kws kho hniav? Nws puas yog ntau tshaj 12 lub hlis lawm txij thaum ib tus kws kho hniav tau tshuaj tus neeg no vim muaj mob los yog raug mob? Puas muaj ib yam dab tsi txog tus neeg no nws kev noj qab haus huv, kev mob nkeeg los yog kev loj hlob uas koj ntxhov siab los yog txhawj xeeb txog? Yog MUAJ, thov piav. Tus neeg no puas siv txoj siv sia los yog lub rooj rau me nyuam zaum txhua zaus thaum nyob hauv tsheb? DID THIS PERSON EVER HAVE OR DOES THIS PERSON NOW HAVE ANY OF THE FOLLOWING? Office Use Yog (Yes) 7 8 Tsis Yog (No) Tsis Paub (Don't Know) Kub ib ce tsis paub piav Tsis qab los los yog pub zaub mov rau noj nyuaj 20 21 Office Use Yog (Yes) Tsis Yog (No) Tsis Paub (Don't Know) Ntuav los yog raws plab Hawb pob los yog ua pa nrov zis zawg

6

TUS NEEG NO PUAS TAU MUAJ LOS YOG TUS NEEG NO TAM SIM NO PUAS MUAJ COV MOB NRAM QAB NO?

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9 10 11 12 13 14 15 16 17 18 19 Office Use Tsis Paub (Don't Know)

Poob ceeb thawj Tsis nco qab lawm Raug tob hau Mob nriaj tes nriaj taw, huam ib tshaj ib tshaj Pheej kheev mob tob hau tsis so Qhov muag muaj teeb meem Mob pob ntseg, qhov ntsej Qhov ntswg kheev los ntshav Hnoos ntev los lawm Muaj Teeb meem tsis hnov lus Cem quav

22 23 24 25 26 27 28 29 30 31

Cov txha sib txua o Plawv pheej nroo nroo Pheej mob plab tsis so Tso quav los ntshav Zais zis, raum, los yog tso zis muaj teeb meem Tso zis los ntshav Ua pob, ua xua, daim tawv nqaij muaj teeb meem Doog los yog los ntshav ntau Kheev dawm ko taw, ntog Kheev mob khaub thuas los yog kheev ua mob

Yog (Yes)

Tsis Yog (No)

TUS NEEG NO PUAS TAU MUAJ TEJ KEV MOB NRAM QAB NO DUA LOS LAWM?
HAS THIS PERSON HAD ANY OF THE FOLLOWING?

32 Qoob qhua pias soob (Rubella) (German measles) Qoob qhua pias (Measles) (Red) Mob qog (Mumps) Mob ib ce ua kub ua no (Rheumatic Fever) Tus neeg no puas fab los yog tsis haum rau tej yam dab tsi (allergies) tam sim no los yog yav tas los? Yog MUAJ, thov piav.

33

34

Tus neeg no puas muaj mob hawb pob (asthma) tam sim no los yog yav tas los?

35

Tus neeg no puas tau raug mob hnyav (accidents) dab tsi yav tas los? Yog MUAJ, thov piav.

36

Tus neeg no puas tau mus pw hauv tsev kho mob, raug phais, muaj mob loj yav tas los? Yog MUAJ, thov piav.

37

Tus neeg no tam sim no puas muaj tej qhov teeb meem uas koj xav, los yog tus kws kho mob tau hais rau koj, tias tej zaum yuav yog ib qho ntawm cov teeb meem tau hais nyob nqi 7 ­ 36? Yog MUAJ, thov piav.

38

Tus neeg no puas PHEEJ KHEEV noj tej yam uas tsis yog khoom noj? (Xws li: av, xim, xaum, clay, starch, ntawv xov xwm.) Yog MUAJ, thov piav.

39 40 41 42 43

Tus neeg no puas muaj teeb meem siv lub dab tso quav los yog teeb meem txog kev xyaum tso quav saum lub dab? Tus neeg no puas raug zoo nrog nws tsev neeg los yog cov nws nrog ua si? Tus neeg no puas muaj teeb meem txog kev kawm? Tus neeg no puas ntsib teeb meem hauv tsev kawm ntawv los yog tsis nyiam kawm ntawv? Tus neeg no puas tau noj cov tshuaj uas kws kho mob ua ntawv kom yuav li 12 lub hlis tas los? Yog noj tshuaj rau dab tsi?

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Tus neeg no puas tau noj cov tshuaj uas tsis yog kws kho mob kom yuav li 12 lub hlis tas los? (Xws li: aspirin, antihistamines, vitamins, food supplements.) Yog noj ne, yog hom tshuaj twg?

45 46 47

Tus neeg no puas tau sim tshuaj txog mob ntsws qhuav es tshwm tias tej zaum ntshe yuav yog? Raug Xa Mus Rau Qhov Kev Ntsuam Xyuas Txog Cov Hluas. TEB RAU COV POJ NIAM YUG UA NTEJ 1972: Leej niam ntawm tus me nyuam no puas tau noj tej tshuaj tiv thaiv kom txhob nchuav me nyuam lub caij nws cev xeeb muaj tus me nyuam no?

KEEB KWM KEV TXHAJ TSHUAJ: Teev hnub uas tus neeg no tau txhaj cov tshuaj nram qab no.
IMMUNIZATION HISTORY: Give the date this person received each of the following.
Hom mob (Koob Tshuaj Yuav Tau Txhaj) (Txhaws qa, mob puab tsaig txhav, thiab hnoos hawb pob) (5 koob thaum pib nkag mus kawm ntawv) DTP (Diphtheria, tetanus, and whooping cough) (5 dose by school entrance) (Mob puab tsaig txhav) (txhua 10 lub xyoo tom qab pib nkag mus kawm ntawv) Td (Tenanus) (every 10 years after school entrance) Mob tuag npab tuag ceg (haus ntawm ncauj mus) (4 zaug thaum pib nkag mus kawm ntawv) Polio Oral (by mouth) (4 dose by school entrance) Mob qoob qhua pias, Mob qog, Qoob qhua pias soob (2 koob thaum pib nkag mus kawm ntawv) Measles, Mumps, Rubella (2 dose by school entrance) Mob khaub thuas hnyav, Hom B (thaum muaj 2, 4, 6 thiab 15 hlis) Hemophilus Influenza, Type B (at 2, 4, 6 and 15 months) None Koob 1 Koob 2 Koob 3 Koob 4 Koob 5

KEV COJ TUS CWJ PWM / TSWJ TUS KHEEJ
BEHAVIORAL / EMOTIONAL HEALTH
Office Use Tsis Yog (No) Tsis Paub (Don't Know) Tus neeg no puas tau muaj ib qho hauv qab no yav tas los: n n Teeb meem kev coj tus cwj pwm los yog tswj tus kheej LOS YOG Mus kho txog teeb meem kev coj tus cwj pwm los yog tswj tus kheej nyob hauv ib qhov chaw kuaj mob (clinic) los yog tsev kho mob (hospital)? Yog TAU mus kho rau qhov twg, thov piav.

Yog (Yes)

47

48

Tus neeg no tsev neeg puas muaj ib tus tau mus kho los yog mus pw hauv tsev kho mob txog teeb meem kev tswj tus kheej xws li kev nyuaj siab, kev ntxhov siab, kev npau taws sai, kev yuav tua tus kheej, los yog kev quav dej caw los yog yeeb tshuaj? Yog MUAJ rau yam twg, thov piav.

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49

Tus neeg no puas tau quav luam yeeb thiab/los yog yeeb tshuaj los li? Yog TAU, thov piav.

50

Tus neeg no puas tau tsis muaj kev cia siab los yog kho siab pheej quaj tsis paub yog ua cas tau npaj siab txo tus kheej txoj sia pheej muaj tej yam xav txawv txawv muaj teeb meem noj khoom los yog pw (ntau dhau los yog tsawg dhau) pheej muaj muaj zog tsis xav so li pheej zoo li yuav ua kom tus kheej raug mob ua tej yam tsis ntshai tsam raug mob pheej hnov tej yam uas lwm leej lwm tus tsis hnov pheej ua tej yam tswj tsis tau tus kheej uas tsis tsim nyog (tej yam ua tsis muaj qab hau dab tsi rau qhov ntawd)

51

Tus neeg no puas muaj tej teeb meem no hauv tsev kawm ntawv? tau qib kawm tsis zoo (poor grades) ntau phooj ywg nyuaj kheev raug rho tawm ntawm tsev kawm ntawv ntaus los yog cam nrog cov phooj ywg los yog cov xib fwb pheej kheev dag los yog ua tub sab pheej mus kawm ntawv tsis cuag ncua

52

Tus neeg no puas muaj tej teeb meem nram qab no hauv tsev los yog hauv zej zog? txav tawm ntawm sawv daws (tsis xav nyob nrog lwm cov) dag los yog nyiag khoom cam los yog sib ntaus nrog tej phooj ywg los yog tej kwv tej tij los yog tej muam tuav rawv tsis tso ib tus niam/txiv, xib fwb, los yog lwm tus neeg khiav tawm hauv tsev mus deb muaj teeb meem nrog tub ceev xwm tsis kam ua raws li niam thiab txiv tej lus qhia, los yog tsis kam mloog cov cai hauv tsev, etc.

Cov Nqe Lus Muab Xa Mus Rau Lwm Qhov Chaw Muab Kev Soj Ntsuam Ntxiv (Criteria for Referral for Further Assessment) 47 and 49 48 50. 51 and 52 Xa mus rau kev soj ntsuam txog laj lim plab plaw yog muaj qhov teb tias yeej muaj (Refer for a psychiatric assessment if there is a positive response.) Xa mus nkaus xwb yog cov nqe lus xa raug rau ib lo lus nug twg lawm (Refer only if referred criteria are met for any other question.) Xa mus rau kev soj ntsuam txog laj lim plab plaw yog tau teb rau ib qho lawm (Refer for a psychiatric assessment if any responses are checked.) Xa mus rau kev soj ntsuam txog laj lim plab plaw yog tau teb rau ib qho los yog ntau qhov lawm (Refer for a psychiatric assessment if two or more responses are checked.)

CEV XEEB TUB & KEV LOJ HLOB
PREGNANCY & DEVELOPMENT Teb rau Txhua Tus Answer for all Ages
Tus no yog tus yug THIB PES TSAWG. Kos rau ntawm lub voj voog seb tus neeg no yog tus yug thib ib, thib ob, li ntawd. Tsis txhob suav cov muam los yog cov nus uas tuag thaum yug los lawm. 1st 2nd 3rd 4th Kos ib qho Kos ib qho 5th Qis dua 17 Qis dua 17 6th 7th 17-39 17-39 8th 40 thiab siab dua 40 thiab siab dua 9th 10th los yog siab dua Tsis paub Tsis paub

NIAM LUB HNUB NYOOG THAUM YUG TUS NO TXIV LUB HNUB NYOOG THAUM YUG TUS NO

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Yog

Tsis Yog (N0)

Tsis Paub (Don't Know

(Yes)

KEEB KWM NTAWM LEEJ NIAM CEV XEEB TUB - Teb rau cov me nyuam QIS DUA 6 XYOO nkaus xwb Puas los ntshav li cas thaum lub caij muaj tus me nyuam no? Tus me nyuam puas yog yug ua ntej nws lub caij? Yog yug ua ntej ne, yog pes tsawg lub lis piam? Puas muaj lwm yam teeb meem los yog muaj mob thaum muaj tus me nyuam no? (Xws li: qoob qhua pias, ntshav siab, ntshav qab zib, tej mob kev sib deev, thiab lwm yam) Yog MUAJ, thov piav. Puas tau muaj tsom duab xob (X-rays) thaum muaj tus me nyuam? Puas tau noj tej tshuaj uas yog kws tshuaj ua ntawv kom yuav los yog lwm yam tshuaj thaum muaj tus me nyuam no? (Xws li: tranquilizers, antibiotics, sedatives, tshuaj noj kom txhob ntuav, tej tshuaj ­ txhaj los yog haus ­ kom txhob nchuav los yog los ntshav) Yog MUAJ, thov piav. Puas tau noj lwm yam tshuaj uas tsis yog kws tshuaj ua ntawv kom yuav thaum muaj tus me nyuam no? (Ib yam li: vitamins, iron supplements, frequent aspirin, etc.) Yog MUAJ, thov piav. Puas muaj tej yam dab tsi pom tias tsis tshua thooj li kev yug me nyuam? Yog MUAJ, thov piav.

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KEV LOJ HLOB - Teb rau cov me nyuam QIS DUA 6 XYOO nkaus xwb

Thaum yug los hnyav: _____lbs. _____ozs. Ntev ______________ inches Kos rau qhov uas tus me nyuam tau ua rau cov sij hawm teev nram qab no: Qhov Muag Ntsia Lawv Raws Yam Khoom Tsis tau tau Ua Ntej 1 hlis 1 - 4 hlis Tob qab 4 hlis Ntxeev Tiaj Tsis tau tau Ua ntej 2 hlis 2 - 5 hlis Tom qab 5 hlis Tig Mus Rau Ntawm Qhov Lub Suab Nrov Tuaj Tsis tau tau Ua ntej 3 hlis 3 - 8 hlis Tom qab 8 hlis Zaum Ib Leeg Tsis tau tau Ua ntej 5 hlis 5 - 9 hlis Tom qab 9 hlis Txaj Muag Rau Cov Neeg Txawv Tsis Paub Tsis tau tau Ua ntej 5 hlis 5 - 10 hlis Tom qab 10 hlis

Mus kev Ib Leeg Tsis tau tau Ua ntej 11 hlis 11 - 15 hlis Tom qab 15 hlis

Hais Tej Lo Lus Tsis tau tau Ua ntej 9 hlis 9 - 12 hlis Tom qab 12 hlis

Hais Tej Kab Lus Tsis tau tau Ua ntej 20 hlis 20 hlis - 2 ½ xyoos Tom qab 2 ½ xyoos

Noj Tej Khoom Xuas Ntiv Tes Tuav Ib Leeg Tsis tau tau Ua ntej 2 xyoos Tom qab 2 xyoos

Siv Khob Haus Dej Ib Leeg Tsis tau tau Ua ntej 2 xyoos Tom qab 2 xyoos

Tau pom zoo tso cai muab kev tshuaj mob kom paub thaum ntxov txog teeb meem kev muaj mob rau ________________________________ (Tus Neeg Mob Lub Npe) thiab muab tej uas tshuaj tau tus mob qhia rau cov chaw thiab cov neeg ua hauj lwm pab txog kev mob nkeeg. Tseem tau pom zoo tso cai ntxiv rau cov chaw kho mob muab tej uas tau hais rau hauv no tso tawm rau cov neeg uas lawv lis txog qhov kev tshuaj mob nkeeg no thiab.

_____________________________________________ KOS NPE

______________________________ Txheeb Ze rau Tus Neeg Mob li cas

____________________ Hnub Kos Npe