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Health Screen and Assessment

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Submitted By Needtogetabsn
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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: Leigh Hinson | Date: 10/19/2015 | Biographical Data | Patient/Client Initials: ECN | Phone No: 910-654-1107 | Address: 6893 Princess Ann Rd. Evergreen NC 28438 | Birth Date:7-20-1999 | Age: 16 | Sex:F | Birthplace: Whiteville, NC | Marital Status:Single | Race/Ethnic Origin: White | Occupation: Cashier | Employer: Food Lion | Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?) She is a full time high school student. She works a part time job as a cashier at a local Food Lion. Her parents and grandparents help her financially. She receives health insurance from her parents. | Source and Reliability of Informant: Patient is very reliable and dependable. | Past Use of Health Care System and Health Seeking Behaviors: None | Present Health or History of Present Illness: Constipation | Past Health History | General Health: (Patient’s own words)Patient states she is in overall good health. | Allergies: (include food and medication allergies) Strawberries | Reaction: Hives | Current Medications:None | Last Exam Date: 4/2015 | Immunizations: All immunizations are up to date. | Childhood Illnesses: None | Serious or Chronic Illnesses: None | Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below) When she was 5 years old she had tubes placed in her ears due to recurrent ear infections. | Past Accidents or Injuries: None | Past Hospitalizations: None | Past Operations: Myringotomy | Family History(Specify which family...

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