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Hea; Th Assessment of Adolescent

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Submitted By slandrum1
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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: Shannon landrum | Date:04/08/16 | Biographical Data | Patient/Client Initials:VPL | Phone No:270-543-8411 | Address:1645 Fairview road Bremen key | Birth Date:02/16/06 | Age:16 | Sex:female | Birthplace: Greenville, KY | Marital Status: single | Race/Ethnic Origin: Caucasian | Occupation: student | Employer: none | Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?)Does not work, father provides insurance | Source and Reliability of Informant:parents | Past Use of Health Care System and Health Seeking Behaviors:Frequent checkups at primary physician | Present Health or History of Present Illness:tonsillitis | Past Health History | General Health: (Patient’s own words)Over all good health with frequent sore throats | Allergies: (include food and medication allergies) NKDA | Reaction: | Current Medications:Oral birth controlAmoxicillin BID x 7 days r/t tonsillitis | Last Exam Date:03/21/16 | Immunizations:Up to date, had at 15 | Childhood Illnesses: tonsillitis | Serious or Chronic Illnesses:Had RSV at age 13 months, reoccurring tonsillitis | Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below) | Past Accidents or Injuries:none | Past Hospitalizations:Hospitalized age 13 months for 3 days related to RSV | Past Operations:none | Family History(Specify which family member is affected.) | Alcoholism (ETOH use/abuse): paternal great uncles | Allergies: mother PCN |

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