Patient/Client Initials: Phone No:
Birth Date: A YearsSex :Female
Birthplace: Marital Status: Single Race/Ethnic Origin:
Occupation: High School StudentEmployer: Unemployed
Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?) She receives health insurance from parents. She is depended, and covered by her mother’s health insurance. Her parents financially support her. Source and Reliability of Informant:
Source is the patient. Patient is very reliable, alert and oriented to time, place, and person.
Past Use of Health Care SysSerious or Chronic Illnesses: None.
Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below) None. Past Accidents or Injuries: When she was seven years, old she fell down and had a fracture on (right) radius. No deformity noted at this time.
Past Hospitalizations: None
(Specify which family member is affected.)
Alcoholism (ETOH use/abuse): None
Allergies: Mother has seasonal allergies and brother is allergic to penicillin. Arthritis: None
Asthma: maternal Grand father
Blood Disorders: none
Breast Cancer: paternal Grand mother
Cancer (Other): None
Cerebral Vascular Accident (Stroke): None
Heart Disease: Her uncle passed away of heart attack.
High Blood Pressure: None
Immunological Disorders: None
Kidney Disease: None
Mental Illness: None
Neurological Disorder: None
Seizure Disorder: None
Obstetric History (if applicable)
Gravida: N/ATerm: N/APreterm: N/AAb/incomplete: N/A
Course of Pregnancy (length of pregnancy, delivery date, method of delivery, length of labor, complications, baby’s weight, baby’s condition): N/A
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? “I am a high school senior preparing to go into college next year. I am an altar server and attend church every Sunday. I am an active member of youth group in church, member of Indian club in the school. I also volunteer in American red cross and shadow a cardiologist two hours/ week.
How would you describe your community?
“My community is a very organized and has a diverse amount of people that are from various countries.”
Hobbies, skills, interests, recreational activities?
She has great interest in music and enjoys singing. She has a passion for dancing, she learned thirteen years Indian classical dance and performed throughout North America.
Military service: Yes_______ No__X_____
If yes, overseas assignment? Yes________ No_________
Close friends or family members who have died within past 2 years? No
Number of relatives or close friends in this area?
Marital status: Single X_____ Married________Divorced_________Separated_________ In serious relationship________ Length of time_________
tem and Health Seeking Behaviors: Has used health care system when in need of health assessment. Client tries to exercise daily and comes to annual checkups.
Present Health or History of Present Illness: Patient is currently healthy. She had no significant past medical history.
Past Health History
General Health: (Patient’s own words)”I have always been healthy. I rarely get sick and when I do it is never serious.”
Allergies: (include food and medication allergies) No known allergies.
Current Medications: Currently patient not taking any medications.
Last Exam Date: 06/01/2011Immunizations:...