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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:
Date:
Biographical Data
Patient/Client Initials: C. M
Phone No:
Address:
Birth Date:
Age: 15
Sex: Female
Birthplace:
Marital Status: Single
Race/Ethnic Origin: White
Occupation: Student
Employer: N/A
Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?)
Income is adequate for life style, patient is a High School Student at the current time, and lives at home with parents, there is a concern regarding her health, regarding asthma, bronchitis at this time. Patient is unemployed, but is covered under parents insurance BCBS.

Source and Reliability of Informant:
Patient is a poor historian, but patients mother is present at the time and is a good historian for patient.

Past Use of Health Care System and Health Seeking Behaviors:

There is a previous use of Health Care System for hospitilation, mother states that the patient does not usually have any health seeking behaviors.

Present Health or History of Present Illness:

Patient during the past 3 days has developed a progressive cough with mild production of green phlegm, and nasal congestion, that has not been relieve with OTC medication, patient states that today she felt very hot, and mother arrived after work and checked oral temperature and it was 100.0 F, Mother states that child has progressively declined and today she has decided to bring her in to be evaluated.

Past Health History
General Health: (Patient’s own words)
“I usually feel ok and like to do things”.

Allergies: (include food and medication...

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