Health History and Screening of an Adolescent or Young Adult Client

Health History and Screening of an Adolescent or Young Adult Client
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Student Name: Date:
Biographical Data
Patient/Client Initials:CM Phone No: [phone]
Address:5 Wallace Street, Fort 400 001
Birth Date: 09/06/1995 Age:23 Sex: Female
Birthplace: Mumbai India Marital Status: Single
Race/Ethnic Origin: Apatanis
Occupation: Student Employer: None
Financial Status: Depends on the parents
Source and Reliability of Informant: Very credible and ascertained by the parents
Past Use of Health Care System and Health Seeking Behaviors: Goes to the hospital on a weekly
basis
Present Health or History of Present Illness: Hypertensive
Past Health History
General Health :Apart from high blood pressure there is no other ailment
Allergies: None Reaction: None
Current Medications:Thiazide diuretics, Angiotensin-converting enzyme (ACE) inhibitors. ...
Angiotensin II receptor blockers (ARBs)and Calcium channel blockers.
Last Exam Date: 27/05/2018 Immunizations: BCG, Polio
Childhood Illnesses: None
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Serious or Chronic Illnesses: High Blood Pressure
Past Health Screening: Done once
Past Accidents or Injuries: Minor eye injury
Past Hospitalizations: None
Past Operations: None
Family History
(Specify which family member is affected.)
Alcoholism (ETOH use/abuse): Father
Allergies: None
Arthritis: Grandmother
Asthma:None
Blood Disorders: None
Breast Cancer: None
Cancer (Other): None
Cerebral Vascular Accident (Stroke): None
Diabetes: Mother
Heart Disease: None
High Blood Pressure: Sister
Immunological Disorders: None
Kidney Disease:None
Mental Illness: None
Neurological Disorder: None
Obesity: Aunt
Seizure Disorder: None
Tuberculosis: None
Obstetric History (if applicable)
Gravida: Term: Preterm: Miscarriage/Abortions:
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Course of Pregnancy : Got pregnant in 2016 and gave birth to a healthy girl in the month of
October.
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?
Basketball and involved in volunteering in case of any disasters
How would you describe your community?
Supportive as it teaches on the skills and issues surrounding self and community care
Hobbies, skills, interests, recreational activities?Travelling, swimming and reading novels
Military service: No
If yes, overseas assignment? No
Close friends or family members who have died within past 2 years? Grandmother
Number of relatives or close friends in this area?13
Marital status: Single______ Married________Divorced_________Separated_________
In serious relationship________ Length of time_________
Environmental Content and Questions:
Do you live alone? No
When did you last move? Never
Describe your living situation? Live with my parents
Number of years of education completed? 15
Occupation?
If employed, how long? Not employed
Are you satisfied with this work situation? No
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