Health History and Screening of an Adolescent or Young Adult Client

This form is used to record the health history and screening of an adolescent or young adult client. It includes biographical data, past and present health history, family history, and review of systems. Nursing diagnoses are also provided based on the health screening.

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: John Mitchell Phone No:
Address: 46/A Brokeland road, New Jersey
Birth Date: 28th October 1993 Age: 24+ Sex: Male
Birthplace: New Jersey Marital Status: Single
Race/Ethnic Origin: Caucasian
Occupation: software developer Employer: XYZ corporations
Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance?
Employment disability?)
Income adequate for lifestyle and maintenance. Health insurance present.
Source and Reliability of Informant:
Shares the relationship of cousin brother
Past Use of Health Care System and Health Seeking Behaviors:
Rarely goes for healthcare screenings, fever last month but did not go for doctor, took antibiotics
Present Health or History of Present Illness:
Morbid obesity
Past Health History
General Health: (Patient’s own words)
I am pretty good but mostly tired. I am bot latherghic and feel like sleeping always. I have issues in breathing in the
night during sleeping
Allergies: (include food and medication allergies)
none
Reaction:
none
Current Medications:
none
Last Exam Date:
Cannot remember
Immunizations:
Chicken pox and measles, hepatitis
Childhood Illnesses:
obesity
Serious or Chronic Illnesses:
obesity
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Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below)
none
Past Accidents or Injuries:
none
Past Hospitalizations:
none
Past Operations:
none
Family History
(Specify which family member is affected.)
Alcoholism (ETOH use/abuse): binge drinking, clubbing
Allergies:no
Arthritis:no but pain in joints sometimes
Asthma:no
Blood Disorders:no
Breast Cancer:no
Cancer (Other):no
Cerebral Vascular Accident (Stroke):no
Diabetes:no
Heart Disease: pain sometimes in chest region
High Blood Pressure: yes
Immunological Disorders: no
Kidney Disease:no
Mental Illness: depression and anxiety
Neurological Disorder: no
Obesity:yes
Seizure Disorder:no
Tuberculosis:no
Obstetric History (if applicable)
Gravida: Term: Preterm: Miscarriage/Abortions:
Course of Pregnancy (length of pregnancy, delivery date, method of delivery, length of labor, complications, baby’s
weight, baby’s condition):
Not applicable
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?
Very lathergic in participating in sports
How would you describe your community?
Community is quite inactive and there is less participation in social events, residents are less participative and do not
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encourage anytypes of health activities
Hobbies, skills, interests, recreational activities?
I mostly play games on playstation. Recently playing pubgee
Military service: Yes_______ No__no_____
If yes, overseas assignment? Yes________ No_________
Close friends or family members who have died within past 2 years? Uncle due to obesity and diabetes
Number of relatives or close friends in this area?
Lives alone
Marital status: Single_yes_____ Married________Divorced_________Separated_________
In serious relationship________Length of time_________
Environmental Content and Questions:
Do you live alone? Yes___yes_____ No ________
When did you last move?
Last five years before
Describe your living situation?
I live luxuriously as I can afford whatever I want
Number of years of education completed?
Last completed bachelors in computer technology
Occupation?
If employed, how long? Three years
Are you satisfied with this work situation? no, it is very strenuous
Do you consider your work dangerous or risky? no
Is your work stressful? Very much stressful or meeting targets, cannot take offs
Over the past 2 years have you felt depressed or hopeless?
I feel depressed about my weight and body image as I feel it is not acceptable in the society
Biophysical Content and Questions
Have you smoked cigarettes? Yes___Yes____ No________
How much?
Less than ½ pack per day_____ About 1 pack per day?__yes____ More than 1 and ½ packs per day______
Are you smoking now? Yes____yes___ No________ Length of time smoking?______________
Have you ever smoked illicit drugs? Yes__________ No___no______
If yes, for how long? _____ no ______ Do you smoke these now? Yes___ no _______ No ___ no _______
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Do you ingest illicit drugs of any kind? Yes_________ No_______ no ___
If so, what drugs do you use and what is the route of ingestion?__no_______
How long have you used these drugs_______no__________
Review of Systems
(Include both past and current health problems. Comment on all present issues.)
General Health State (present weight – gain or loss, reason for gain or loss, amount of time for gain or loss; fatigue,
malaise, weakness, sweats, night sweats, chills ):
Huhe increase in weight due to sedentary lifestyles, cannot get moments off from off to have a free walk, have to
carry takeaway foods as no time to prepare food in home.
Skin (history of skin disease, pigment or color change, change in mole, excessive dryness or moisture, pruritis,
excessive bruising, rash or lesion):
no
Health Promotion (Sun exposure? Skin care products?):
no
Hair (recent loss or change in texture):
no
Health Promotion (method of self-care, products used for care):
Nails (change in color, shape, brittleness):
no
Health Promotion (method of self-care, products used for care):
Head (unusual headaches, frequency of headaches, head injury, dizziness, syncope or vertigo):
no
Eyes (difficulty or change in vision, decreased acuity, blurring, blind spots, eye pain, diplopia, redness or swelling,
watering or discharge, glaucoma or cataracts):
no
Health Promotion (wears glasses or contacts and reason, last vision check, last glaucoma check, sun protection):
Ears (earaches, infections, discharge and its characteristics, tinnitus or vertigo):
no
Health Promotion (hearing loss, hearing aid use, environmental noise exposure, methods for cleaning ears):
Nose and Sinuses (discharge and its characteristics, frequent or severe colds, sinus pain, nasal obstruction,
nosebleeds, seasonal allergies, change in sense of smell):
no
Health Promotion (methods for cleaning nose):
Mouth and Throat (mouth pain, sore throat, bleeding gums, toothache, lesions in mouth, tongue, or throat,
dysphagia, hoarseness, tonsillectomy, alteration in taste):
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no
Health Promotion (Daily dental care – brushing, flossing. Use of prosthetics – bridges, dentures. Last dental
exam/check-up.): no
Neck (pain, limitation of motion, lumps or swelling, enlarged or tender lymph nodes, goiter):
no
Neurologic System (history of seizure disorder, syncopal episodes, CVA, motor function or coordination
disorders/abnormalities, paresthesia, mood change, depression, memory disorder, history of mental health
disorders):
no
Health Promotion (activities to stimulate thinking, exam related to mood changes/depression):
Endocrine System (history of diabetes or insulin resistance, history of thyroid disease, intolerance to heat or cold):
no
Health Promotion (last blood glucose test and result, diet):
Breast and Axilla (pain, lump, tenderness, swelling, rash, nipple discharge, any breast surgery):
no
Health Promotion (performs breast self-exam – both male and female, last mammogram and results, use of self-care
products):
Respiratory System (History of lung disease, smoking, chest pain with breathing, wheezing, shortness of breath,
cough – productive or nonproductive. Sputum – color and amount. Hemoptysis, toxin or pollution exposure.):
Issue in breathing during the night
Health Promotion (last chest x-ray, smoking cessation):
Cardiac System (history of cardiac disease, MI, atherosclerosis, arteriosclerosis, chest pain, angina):
Pain in chest sometimes
Health Promotion (last cardiac exam):
Peripheral Vascular System (coldness, numbness, tingling, swelling of legs/ankles, discoloration of hands/feet,
varicose veins, intermittent claudication, thrombophlebitis or ulcers):
no
Health Promotion (avoid crossing legs, avoid sitting/standing for long lengths of time, promote wearing of support
hose):
Hematologic System (bleeding tendency of skin or mucous membranes, excessive bruising, swelling of lymph nodes,
blood transfusion and any reactions, exposure to toxic agents or radiation):
no
Health Promotion (use of standard precautions when exposed to blood/body fluids):
Gastrointestinal System (appetite, food intolerance, dysphagia, heartburn, indigestion, pain [with eating or other],
pyrosis, nausea, vomiting, history of abdominal disease, gastric ulcers, flatulence, bowel movement frequency,
change in stool [color, consistency], diarrhea, constipation, hemorrhoids, rectal bleeding):
no
Health Promotion (nutrition – quality/quantity of diet; use of antacids/laxatives):
Musculoskeletal System (history of arthritis, joint pain, stiffness, swelling, deformity, limitation of motion, pain,
cramps or weakness):limitation of motion, weakness, pain in joints of knee
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Health Promotion (mobility aids used, exercises, walking, effect of limited range of motion):
Urinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or straining,
urine color, narrowed stream, incontinence; history of urinary disease; pain in flank, groin, suprapubic region or
low back):
no
Health Promotion (methods used to prevent urinary tract infections, use of feminine hygiene products, Kegel
exercises):
Male Genital System (penis or testicular pain, sores or lesions, penile discharge, lumps, hernia):
no
Health Promotion (performs testicular self-exam):
Female Genital System (menstrual history, age of first menses, last menstrual cycle, frequency of cycles,
premenstrual pain, vaginal itching, discharge, premenopausal symptoms, age at menopause, postmenopausal
bleeding):
no
Health Promotion (last gynecological checkup, pap-smear and results, use of feminine hygiene products):
Sexual Health (presently involved in relationship involving intercourse or other sexual activity, aspects of sex
satisfactory, use of contraceptive, is relationship monogamous, history of STD):
Health Promotion (safe-sex practices):
no
Nursing Diagnoses:
Based on this health history and health screening, identify three nursing diagnoses that would be
applicable for this client as well as your rationale for your selection of each nursing diagnosis.
Include:
One “actual” nursing diagnosis with rationale for choice of this diagnosis.
The patient had been suffering from obesity. His weight and height had been considered and
BMI had been calculated. This gives a value of about 32 which puts him into a risk of various
types of health issues like diabetes, osteoarthristis, cancer and many others (Bleich et al., 2015)
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One wellness nursing diagnosis with rationale for choice of this diagnosis.
He is having issues with his breathing durng the time of sleeping. Therefore he is not being able
to complete his sleeping hours for which he is feeling lathergic throughout the day. He is having
chronic daytime sleepiness issues, difficulty in concentrating on work, falling asleep while
working and many others. This is making him stressed as he is not being able to provide full
potential. He is also depressed due to his body image which might make him socially excluded
(Shoemaker et al., 2016).
One “risk for” nursing diagnosis based on the health screening with rationale for choice of this
diagnosis.
The patient has high blood pressure and is at the risk of developin cardiac heart failure issues. Obesity causes
increased volume of blood, elevation of the cardiac output, left ventricular hypertrophy, left ventricular dysfunction
and many other issues (Cha et al., 2015). These exposes the individuals to develop cardiac failure. Hypertensions
increases the riks by many folds (Bakken et al., 2014).
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References:
Bakken, S., Jia, H., Chen, E. S., Choi, J., John, R. M., Lee, N. J., ... & Currie, L. M. (2014). The
effect of a mobile health decision support system on diagnosis and management of
obesity, tobacco use, and depression in adults and children. The Journal for Nurse
Practitioners, 10(10), 774-780.
Bleich, S. N., Bandara, S., Bennett, W. L., Cooper, L. A., & Gudzune, K. A. (2015). US health
professionals’ views on obesity care, training, and self-efficacy. American journal of
preventive medicine, 48(4), 411-418.
Cha, E., Akazawa, M. K., Kim, K. H., Dawkins, C. R., Lerner, H. M., Umpierrez, G., & Dunbar,
S. B. (2015). Lifestyle habits and obesity progression in overweight and obese American
young adults: Lessons for promoting cardiometabolic health. Nursing & health
sciences, 17(4), 467-475.
Shoemaker, M. L., White, M. C., Hawkins, N. A., & Hayes, N. S. (2016, July). Prevalence of
smoking and obesity among US cancer survivors: Estimates from the national health
interview survey, 2008–2012. In Oncology nursing forum (Vol. 43, No. 4, p. 436). NIH
Public Access.
© 2016. Grand CanyonUniversity. All Rights Reserved.