Health History and Screening of

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: April 20, 2013 | Biographical Data | Patient/Client Initials: MT | Phone No: | Address: | Birth Date: 10/19/1994 | Age:18 | Sex Female | Birthplace: Richmond, VA | Marital Status: Single | Race/Ethnic Origin: African American | Occupation: Cashier | Employer:VCU Health System | Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?)Patient works part-time as a cashier and requires assistant to supplement her income. She receives monthly food stamps and funds from her maternal grandmother to help with living expenses. Medical, dental and vision insurance coverage is available through the patient’s mother. She has no disability limiting her from working or engaging in other activities | Source and Reliability of Informant:Information obtained from patient who is a good historian and is well informed about her health history | Past Use of Health Care System and Health Seeking Behaviors:She uses the health care system for episodic illnesses and recently sought medical care for UTI. Patient understand the importance of obtaining health care when necessary as demonstrated her recent visit to the doctor to for UTI | Present Health or History of Present Illness:Patiently she has chronic UTI related to congenital overactive bladder and pre-hypertension | General Health: (Patient’s own words)“Although I have high blood pressure and chronic UTI’s, I feel I am fairly healthy” | Allergies: (include food and medication allergies) NKA | Reaction:N/A | Current Medications:Depro Provera Q 3 months ;