Health History Screening Adolescent
Health History and Screening of an Adolescent or Young Adult Client
Save this form on your computer as a Microsoft Word document. You can expand or shrink each area as you need to include the relevant data for your client. Submit this resource with your assignment to the instructor by the end of Module 3.
|Student Name: |Date: |
|Biographical Data |
|Patient/Client Initials: |Phone No: |
|Address: |
|Birth Date: |Age: |Sex: |
|Birthplace: |Marital Status: |
|Race/Ethnic Origin: |
|Occupation: |Employer: |
|Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?) |
| |
|Source and Reliability of Informant: |
|
Save this form on your computer as a Microsoft Word document. You can expand or shrink each area as you need to include the relevant data for your client. Submit this resource with your assignment to the instructor by the end of Module 3.
|Student Name: |Date: |
|Biographical Data |
|Patient/Client Initials: |Phone No: |
|Address: |
|Birth Date: |Age: |Sex: |
|Birthplace: |Marital Status: |
|Race/Ethnic Origin: |
|Occupation: |Employer: |
|Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?) |
| |
|Source and Reliability of Informant: |
|