Screening for Health

¶ … 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: CLW Phone No: [HIDDEN] 123 Anywhere Lane, Some Town, Some State 00000 Birth Date: 03 -09-90 Age Sex: female Birthplace: Some State Marital Status: n/a Race/Ethnic Origin: African America Occupation: n/a Employer: student Financial Status: This patient is from a low-income family whose father is deceased and mother is disabled receiving only minimal income. The family receives food stamps and has Medicaid benefits. Source and Reliability of Informant: The 14-year-old female is accompanied by her aunt who is a credible source of information.

Past Use of Health Care System and Health Seeking Behaviors: The child has not been seen regularly by a pediatrician during her childhood. Vaccinations are not up-to-date. Present Health or History of Present Illness: This 14-year-old female presents with obesity. Past Health History General Health: My stomach does not feel good. I just don't feel good. My teeth hurt and my head hurts. Allergies: (include food and medication allergies) No known allergies Reaction: n/a Current Medications: Patient states she takes tums quite regularly for indigestion.

Last Exam Date: Patient was examined 1 year ago at the emergency room with irritable bowels. Immunizations: Not up-to-date. Childhood Illnesses: This 14-year-old female and her aunt report no serious childhood illnesses although she has had pneumonia on several occasions. Serious or Chronic Illnesses: This 14-year-old female is overweight and obese. 0/ Past Health Screening The 14-year-old females father was an alcoholic, suffered a stroke and the child's mother has arthritis, diabetes, heart disease, and high blood pressure.

Past Accidents or Injuries: n/a Past Hospitalizations: No inpatient admissions Past Operations: n/a Family History (Specify which family member is affected.) Alcoholism (ETOH use/abuse): Father Allergies: n/a Arthritis: Mother Asthma: Mother Blood Disorders: n/a Breast Cancer: n/a Cancer (Other): n/a Cerebral Vascular Accident (Stroke): Father Diabetes: Mother Heart Disease: Mother High Blood Pressure: Mother Immunological Disorders: n/a Kidney Disease: Father Mental Illness: n/a Neurological Disorder: n/a Obesity: Mother and Father Seizure Disorder: n/a Tuberculosis: n/a Obstetric History (if applicable) Gravida: Term: Preterm: Miscarriage/Abortions: 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? The patient attends church on Sunday.

No other community activities. How would you describe your community? This female described her community as poor and dull. Hobbies, skills, interests, recreational activities? The patient reports that her interests include only watching television and playing video games. Military service: Yes____ No____x If yes, overseas assignment? Yes____ No Close friends or.