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¶ … 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. No other community activities.
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
...
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 family members who have died within past 2 years? Her father died two years ago.
Number of relatives or close friends in this area? She has only her mother, two siblings and her aunt.
Marital status: Single____x____ Married____Divorced____Separated
In serious relationship____ Length of time
Environmental…
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