Teen Health Assessment

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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. Student Name: Mary Koke| Date: December 6th, 2012|

Biographical Data|
Patient/Client Initials: A.K.| Phone No: 222-555-1234|
Address: 123 Smith St. |
Birth Date: September 8,1999| Age: 13 yrs.| Sex: Male|
Birthplace: Racine, WI | Marital Status: Single| Race/Ethnic Origin: Caucasian |
Occupation: Student| Employer: too young to work|
Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?)Patient is supported financially by parents. Health insurance is through the father’s place of work.| Source and Reliability of Informant:Information provided by patient and patient’s biological mother. Both sources appear competent and reliable. | Past Use of Health Care System and Health Seeking Behaviors:Patients has seeked health care system for general health maintenance only.| Present Health or History of Present Illness:Patient appears to be in good health with signs or symptoms of illness or disease present. Alert, orientated, and without pain.| Past Health History|

General Health: (Patient’s own words)“Good” |
Allergies: (include food and medication allergies) No known Allergies| Reaction:Does not apply since patient does not have allergies| Current Medications:Patient does not take any medications.| Last Exam Date:May 2012, physical.| Immunizations:Current and up to date| Childhood Illnesses:Patient does not have any childhood illnesses. | Serious or Chronic Illnesses:Patient does not have any serious or chronic illnesses. | Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below)Information provided below| Past Accidents or Injuries:No accidents or injuries experienced by patient.| Past Hospitalizations:No past hospitalizations experienced by patient.| Past Operations:Patient has not had any operations. |

Family History(Specify which family member is affected.)|
Alcoholism (ETOH use/abuse): No family history.|
Allergies: Some seasonal allergies experienced by biological mother. | Arthritis: No family history.|
Asthma: No family history.|
Blood Disorders: No family history.|
Breast Cancer: No family history.|
Cancer (Other): No family history.|
Cerebral Vascular Accident (Stroke): No family history.|
Diabetes: Biological grandmother on mother’s side Type 2 diabetic.| Heart Disease: No family history.|
High Blood Pressure: No family history.|
Immunological Disorders: No family history.|
Kidney Disease: No family history.|
Mental Illness: Biological grandfather on mother’s side has occasional periods of depression related to loss of work.| Neurological Disorder: No family history.|
Obesity: No family history.|
Seizure Disorder: No family history.|
Tuberculosis: No family history.|
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? “None” Patient is not involved in any activities besides attending school at this time.How would you describe your community?“Big city”. Patient resides in a city with a population of around 100,000 people.Hobbies, skills, interests, recreational activities?“Playing guitar, hanging out with friends and playing video games”....
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