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.

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…