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. Submit this resource with your assignment to the instructor by the end of Module 3.
|Student Name: |Date: |
|Biographical Data | |Patient/Client Initials: |Phone No: | |Address: | |Birth Date: |Age: |Sex: | |Birthplace: |Marital Status: | |Race/Ethnic Origin: | |Occupation: |Employer: | |Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?) | | | |Source and Reliability of Informant: | | | |Past Use of Health Care System and Health Seeking Behaviors: | | | |Present Health or History of Present Illness: | | | |Past Health History | |General Health: (Patient’s own words) | | | |Allergies: (include food and medication allergies) |Reaction: | | | | |Current Medications: | | | |Last Exam Date: |Immunizations: | | | | | |...
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