Health History And Screening of an Adolescent or Young Adult Client
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Patient/Client Initials: Julio Molina
Phone No: XXX-XXX-XXXX
Birthplace: Tucson, AZ
Marital Status: Single
Race/Ethnic Origin: Mexican-American
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)
Current Medications: Aspirin for the muscle soreness and headaches.
Last Exam Date: 4/24/1998
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)