Health History and Screening of an Adolescent or Young Adult Client.
Health History and Screening of an Adolescent or Young Adult Client
Student Name:
Biographical Data
Patient/Client Initials: Phone No:
Address:
Birth Date: A Years Sex :Female
Birthplace: Marital Status: Single
Race/Ethnic Origin:
Occupation: High School Student Employer: Unemployed
Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?) She receives health insurance from parents. She is depended, and covered by her mother’s health insurance. Her parents financially support her.
Source and Reliability of Informant:
Source is the patient. Patient is very reliable, alert and oriented to time, place, and person.
Past Use of Health Care SysSerious or Chronic Illnesses: None.
Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below) None.
Past Accidents or Injuries: When she was seven years, old she fell down and had a fracture on (right) radius. No deformity noted at this time.
Past Hospitalizations: None
Past Operations:
None.
Family History
(Specify which family member is affected.)
Alcoholism (ETOH use/abuse): None
Allergies: Mother has seasonal allergies and brother is allergic to penicillin.
Arthritis: None
Asthma: maternal Grand father
Blood Disorders: none
Breast Cancer: paternal Grand mother
Cancer (Other): None
Cerebral Vascular Accident (Stroke): None
Diabetes: None
Heart Disease: Her uncle passed away of heart attack.
High Blood Pressure: None
Immunological Disorders: None
Kidney Disease: None
Mental Illness: None
Neurological Disorder: None
Obesity: None
Seizure Disorder: None
Tuberculosis: None
Obstetric History (if applicable)
Gravida: N/A Term: N/A Preterm: N/A Ab/incomplete: N/A
Course of Pregnancy (length of pregnancy, delivery date, method of delivery, length of labor, complications, baby’s
Student Name:
Biographical Data
Patient/Client Initials: Phone No:
Address:
Birth Date: A Years Sex :Female
Birthplace: Marital Status: Single
Race/Ethnic Origin:
Occupation: High School Student Employer: Unemployed
Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?) She receives health insurance from parents. She is depended, and covered by her mother’s health insurance. Her parents financially support her.
Source and Reliability of Informant:
Source is the patient. Patient is very reliable, alert and oriented to time, place, and person.
Past Use of Health Care SysSerious or Chronic Illnesses: None.
Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below) None.
Past Accidents or Injuries: When she was seven years, old she fell down and had a fracture on (right) radius. No deformity noted at this time.
Past Hospitalizations: None
Past Operations:
None.
Family History
(Specify which family member is affected.)
Alcoholism (ETOH use/abuse): None
Allergies: Mother has seasonal allergies and brother is allergic to penicillin.
Arthritis: None
Asthma: maternal Grand father
Blood Disorders: none
Breast Cancer: paternal Grand mother
Cancer (Other): None
Cerebral Vascular Accident (Stroke): None
Diabetes: None
Heart Disease: Her uncle passed away of heart attack.
High Blood Pressure: None
Immunological Disorders: None
Kidney Disease: None
Mental Illness: None
Neurological Disorder: None
Obesity: None
Seizure Disorder: None
Tuberculosis: None
Obstetric History (if applicable)
Gravida: N/A Term: N/A Preterm: N/A Ab/incomplete: N/A
Course of Pregnancy (length of pregnancy, delivery date, method of delivery, length of labor, complications, baby’s
References: Breast cancer-PubMed Health.(n.d.).National Center for Biotechnology Information. Retrieved July 17,2012, from http://www.ncbi.gov/pubmedhealth/PMH0001911 Edelman,C.L.,& Mandle,C.L. (201). Health promotion: Throughout the life span (7th ed). St. Louis, MO: Mosby. Jarvis, C.(2012).Physical examination & health assessment (6t ed.).St. Louis, MO: Saunders.