Health Screening wk3
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.
Student Name:
Date:
Biographical Data
Patient/Client Initials: WT
Phone No
Address:
Birth Date: 1993
Age: 21
Sex: M
Birthplace:
Marital Status: Single
Race/Ethnic Origin: Caucasian
Occupation:
Employer:
Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?)
Inadequate income as client is a full time student and only works part time. Health insurance coverage is provided under his families plan. No health concerns or employment disabilities have been identified.
Source and Reliability of Informant:
Data given by the client himself. He has no cognitive deficits and is alert and oriented.
Past Use of Health Care System and Health Seeking Behaviors:
No previous hospitalizations. Client utilizes his primary care physician for annual checkups. Client has been to the emergency room 3 times in the past 5 years for sports related injuries.
Present Health or History of Present Illness:
Client reports no health deficits at this time.
Past Health History
General Health: (Patient’s own words)
“I am healthy. I exercise a few times a week. I haven’t had any reason to see my doctor lately.”
Allergies: (include food and medication allergies)
No Known food or medication allergies
Reaction:
Not applicable
Current Medications:
Not Applicable
Last Exam Date:
Jan, 2014
Immunizations:
Annual Flu vaccine 10/2013, Meningococcal conjugate vaccine, Tdap, and all childhood vaccinations
Childhood Illnesses:
Chicken Pox at age 5
Serious or Chronic Illnesses: Not Applicable
Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below)
Past Accidents or
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.
Student Name:
Date:
Biographical Data
Patient/Client Initials: WT
Phone No
Address:
Birth Date: 1993
Age: 21
Sex: M
Birthplace:
Marital Status: Single
Race/Ethnic Origin: Caucasian
Occupation:
Employer:
Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?)
Inadequate income as client is a full time student and only works part time. Health insurance coverage is provided under his families plan. No health concerns or employment disabilities have been identified.
Source and Reliability of Informant:
Data given by the client himself. He has no cognitive deficits and is alert and oriented.
Past Use of Health Care System and Health Seeking Behaviors:
No previous hospitalizations. Client utilizes his primary care physician for annual checkups. Client has been to the emergency room 3 times in the past 5 years for sports related injuries.
Present Health or History of Present Illness:
Client reports no health deficits at this time.
Past Health History
General Health: (Patient’s own words)
“I am healthy. I exercise a few times a week. I haven’t had any reason to see my doctor lately.”
Allergies: (include food and medication allergies)
No Known food or medication allergies
Reaction:
Not applicable
Current Medications:
Not Applicable
Last Exam Date:
Jan, 2014
Immunizations:
Annual Flu vaccine 10/2013, Meningococcal conjugate vaccine, Tdap, and all childhood vaccinations
Childhood Illnesses:
Chicken Pox at age 5
Serious or Chronic Illnesses: Not Applicable
Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below)
Past Accidents or