Health History And Screening of an Adolescent or Young Adult Client
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Biographical Data
Patient/Client Initials: Julio Molina
Phone No: XXX-XXX-XXXX
Birth Date:1/28/1999
Age:15
Sex: Male
Birthplace: Tucson, AZ
Marital Status: Single
Race/Ethnic Origin: Mexican-American
Occupation: Student
Employer: N/A
Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?) Patient is a freshman in high school and thus has no income, however, his parents have health insurance which covers Julio.
Source and Reliability of Informant: Information obtained directly from the patient.
Past Use of Health Care System and Health Seeking Behaviors: Patient visits a general health care clinic during instances of poor health and illness.
Present Health or History of Present Illness: Patient exhibits no signs of serious illness, however, he has reported excess thirst and urination, random bouts of fatigue/muscle soreness/headache, and occasional issues with his eyesight.
Past Health History
General Health: (Patient's own words)
"I feel fine for the most part, but every so often I have trouble seeing, almost like I am going blind. During the day, I find myself becoming very thirsty no matter how much water or Gatorade I drink, and this leads to me using the restroom much more often than normal. Also, my muscles are sore sometimes and I feel tired even when I got a good night's sleep, and I get terrible headaches."
Allergies: (include food and medication allergies)
None reported.
Reaction:
N/A
Current Medications: Aspirin for the muscle soreness and headaches.
Last Exam Date: 4/24/1998
Immunizations:
unizations:
Current and full.
Childhood Illnesses: None reported.
Serious or Chronic Illnesses: None reported.
Past Health Screening (see "Well Young Adult Behavior Health Assessment History Screening" below)
Past Accidents or Injuries: None reported.
Past Hospitalizations: None reported.
Past Operations: None reported.
Family History
(Specify which family member is affected.)
Alcoholism (ETOH use/abuse): Grandparents on both sides
Allergies: N/A
Arthritis: Fraternal grandmother and uncle on father's side
Asthma: N/A
Blood Disorders: Low blood sugar/both parents
Breast Cancer: N/A
Cancer (Other): N/A
Cerebral Vascular Accident (Stroke):
Diabetes: Mother, Uncle and multiple cousins
Heart Disease: N/A
High Blood Pressure: N/A
Immunological Disorders: N/A
Kidney Disease: Multiple members of family on both sides
Mental Illness: N/A
Neurological Disorder: N/A
Obesity: Multiple members of family on both sides
Seizure Disorder: N/A
Tuberculosis: N/A
Obstetric History (if applicable)
Gravida:
Term:
Preterm:
Ab/incomplete:
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?
Patient plays soccer, basketball and baseball for his high school, participates actively in a local Catholic Church youth group, and achieves high scores in school.
How would you describe your community?
Patient's community is a urban area in…
