Health History and Screening of an Adolescent or Young Adult Client
Health History and Screening of an Adolescent or Young Adult Client
Student Name:
Date: January 26, 2014
Biographical Data
Patient/Client Initials: CB
Phone No: 602-388-1612
Address: 115 W. Coronodo Road, Phoenix, AZ 85003
Birth Date: 12/05/98
Age: 15
Sex: M
Birthplace: Phoenix
Marital Status: Single
Race/Ethnic Origin: White
Occupation: Student
Employer: N/A
Financial Status:
Aetna Health Insurance
Source and Reliability of Informant: Self – CB and mother MB
Past Use of Health Care System and Health Seeking Behaviors:
Fracture of left tibia status post skateboard accident (06/2012)
Asthma Attack (08/2012)
Present Health or History of Present Illness:
Complaint of asthma
Past Health History
General Health:
“I have asthma attacks, but otherwise feel good. I’m still having problems with my left leg but I’m working on it”
Allergies:
Sulfa
Reaction:
Rash
Current Medications:
Esiflo Inhaler, PRN
Last Exam Date:
08/19/2013 – School Physical
07/2013 – Eye
08/2013 - Dental
Immunizations:
Up to date according to mother, MB
Childhood Illnesses:
Chicken Pox and Strep Throat
Serious or Chronic Illnesses:
Asthma
Past Health Screening:
(see “Well Young Adult Behavior Health Assessment History Screening” below)
Past Accidents or Injuries:
Fracture left tibia, skateboard accident, 06/2012
Past Hospitalizations:
Inpatient for Open Reduction Internal Fixation left tibia fracture, 06/2012
Asthma, 08/2013
Past Operations:
Open Reduction Internal Fixation (ORIF) left tibia fracture, 06/2012
Family History
Alcoholism (ETOH use/abuse): None
Allergies: Mother, 51 years old – Adhesive Tape, Sulfa, Morphine
Arthritis: Grandmother (maternal), 72 years old, systemic Aunt (paternal), 56 years old, hands and knees
Asthma: Brother, 9 years old, inhaler use
Blood Disorders: None
Breast Cancer:
Student Name:
Date: January 26, 2014
Biographical Data
Patient/Client Initials: CB
Phone No: 602-388-1612
Address: 115 W. Coronodo Road, Phoenix, AZ 85003
Birth Date: 12/05/98
Age: 15
Sex: M
Birthplace: Phoenix
Marital Status: Single
Race/Ethnic Origin: White
Occupation: Student
Employer: N/A
Financial Status:
Aetna Health Insurance
Source and Reliability of Informant: Self – CB and mother MB
Past Use of Health Care System and Health Seeking Behaviors:
Fracture of left tibia status post skateboard accident (06/2012)
Asthma Attack (08/2012)
Present Health or History of Present Illness:
Complaint of asthma
Past Health History
General Health:
“I have asthma attacks, but otherwise feel good. I’m still having problems with my left leg but I’m working on it”
Allergies:
Sulfa
Reaction:
Rash
Current Medications:
Esiflo Inhaler, PRN
Last Exam Date:
08/19/2013 – School Physical
07/2013 – Eye
08/2013 - Dental
Immunizations:
Up to date according to mother, MB
Childhood Illnesses:
Chicken Pox and Strep Throat
Serious or Chronic Illnesses:
Asthma
Past Health Screening:
(see “Well Young Adult Behavior Health Assessment History Screening” below)
Past Accidents or Injuries:
Fracture left tibia, skateboard accident, 06/2012
Past Hospitalizations:
Inpatient for Open Reduction Internal Fixation left tibia fracture, 06/2012
Asthma, 08/2013
Past Operations:
Open Reduction Internal Fixation (ORIF) left tibia fracture, 06/2012
Family History
Alcoholism (ETOH use/abuse): None
Allergies: Mother, 51 years old – Adhesive Tape, Sulfa, Morphine
Arthritis: Grandmother (maternal), 72 years old, systemic Aunt (paternal), 56 years old, hands and knees
Asthma: Brother, 9 years old, inhaler use
Blood Disorders: None
Breast Cancer:
References: Gradishar, D., Muzio, L., Filipski, A. & Klopp, A. (n.d.). Retrieved from http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick39.html Martucci, S. & Gulanick, M. (n.d.). Retrieved from http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick27.html Nursing Diagnosis. (n.d.). Retrieved from http://www1.us.elsevierhealth.com/SIMON/Ulrich/Constructor/diagnoses.cfm?did=338 Weber, J. R. (2005). Retrieved from http://jxzy.smu.edu.cn/jkpg/UploadFiles/file/TF_06928152357_nursing%20diagnoses%20grouped%20by%20functional%20health%20patterns.pdf