Adolescent health screenGCU

Topics: Family, Nursing, Medicine Pages: 10 (1986 words) Published: March 15, 2014
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: January 28, 2014
Biographical Data
Patient/Client Initials: Phone No: N/A
Birth Date: Age: 12Sex: f
Birthplace: Upland, CA. Marital Status: Single Race/Ethnic Origin: Caucasian
Occupation: StudentEmployer:N/A
Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?) Insurance provided by parent

Source and Reliability of Informant:
Informant: Client, Reliable

Past Use of Health Care System and Health Seeking Behaviors: Routine exams and vaccinations

Present Health or History of Present Illness:
Present health is good

Past Health History
General Health: (Patient’s own words)
“I only get sick when my little brother brings something home”

Allergies: (include food and medication allergies) NKA

Current Medications:

Last Exam Date: 8/2013Immunizations:

Childhood Illnesses:

Serious or Chronic Illnesses:

Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below) Past Accidents or Injuries:

Past Hospitalizations:

Past Operations:

Family History
(Specify which family member is affected.)
Alcoholism (ETOH use/abuse): Maternal grandfather
Allergies:Mother and brother-seasonal; maternal grandmother- penicillin Arthritis:N/A
Asthma: Maternal Aunt
Blood Disorders:N/A
Breast Cancer:Maternal great grandmother
Cancer (Other): Bladder- maternal grat uncle
Cerebral Vascular Accident (Stroke):Paternal grandfather
Diabetes:Maternal grandfather
Heart Disease:N/A
High Blood Pressure:Father
Immunological Disorders:N/A
Kidney Disease:N/A
Mental Illness:N/A
Neurological Disorder:N/A
Seizure Disorder:N/A
Obstetric History (if applicable)
Course of Pregnancy (length of pregnancy, delivery date, method of delivery, length of labor, complications, baby’s weight, baby’s condition):

Well Young Adult Behavioral Health History Screening
Socio-Demographic Content and Questions:

What organizations or activities (community, school, church, lodge, social, professional, academic, sports) are you involved in? Softball, GATE, Science club, and Soccer

How would you describe your community?
“It’s nice. Sometimes it gets boring but I like it here.” Hobbies, skills, interests, recreational activities?
“I like making crafts like bracelets and I also like to make things out of colorful duct tape.” Military service: Yes_______ No_x______
If yes, overseas assignment? Yes________ No_________

Close friends or family members who have died within past 2 years? N/A
Number of relatives or close friends in this area?

“Most of my family and all my friends live around me. I only have two uncle that live far away {San Diego}”.

Marital status: Single_x_____ Married________Divorced_________Separated_________ In serious relationship________ Length of time_________

Environmental Content and Questions:

Do you live alone? Yes________ No __x______

When did you last move?
“My mom moved 3 years ago and my dad moved 2 years ago.” Describe your living situation?

Number of years of education completed?
Occupation? Student
If employed, how long?
Are you satisfied with this work situation?
Do you consider your work dangerous or risky?
Is your work stressful?

Over the past 2 years have you felt depressed or hopeless?

Biophysical Content and Questions

Have you smoked cigarettes? Yes_______ No___x_____

How much?
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