What organizations or activities (community, school, church, lodge, social, professional, academic, sports) are you involved in?

What organizations or activities (community, school, church, lodge, social, professional, academic, sports) are you involved in?

HEALTH HISTORY AND SCREENING OF AN ADOLESCENT OR YOUNG ADULT CLIENT

Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?)

Source and Reliability of Informant:

Past Use of Health Care System and Health Seeking Behaviors:

Present Health or History of Present Illness:

Past Health History
General Health: (Patient’s own words)

Allergies: (include food and medication allergies)

Reaction:

Current Medications:

Last Exam Date: Immunizations:

Childhood Illnesses:

Serious or Chronic Illnesses:

Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below)

Tuberculosis:
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):

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?

How would you describe your community?

Hobbies, skills, interests, recreational activities?

Military service: Yes_______ No_______
If yes, overseas assignment? Yes________ No_________

Close friends or family members who have died within past 2 years?

Number of relatives or close friends in this area?

Marital status: Single______ Married________Divorced_________Separated_________
In serious relationship________Length of time_________

Environmental Content and Questions:

Do you live alone? Yes________ No ________

When did you last move?

Describe your living situation?


 

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