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?)
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: (Patients 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 babys weight babys 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?
Number of years of education completed?
Occupation?
If employed how long?
Are you satisfied with this work situation?
Do you consider your work dangerous or risky?
Is your work stressful?
Over the past 2 years have you felt depressed or hopeless?
Biophysical Content and Questions
Have you smoked cigarettes? Yes_______ No________
How much?
Less than pack per day_____ About 1 pack per day?______ More than 1 and packs per day______
Are you smoking now? Yes_______ No________ Length of time smoking?______________
Have you ever smoked illicit drugs? Yes__________ No_________
If yes for how long? ___________ Do you smoke these now? Yes__________ No __________
Do you ingest illicit drugs of any kind? Yes_________ No__________
If so what drugs do you use and what is the route of ingestion?_________
How long have you used these drugs_________________
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 ):
Skin (history of skin disease pigment or color change change in mole excessive dryness or moisture pruritis excessive bruising rash or lesion):
Health Promotion (Sun exposure? Skin care products?):
Hair (recent loss or change in texture):
Health Promotion (method of self-care products used for care):
Nails (change in color shape brittleness):
Health Promotion (method of self-care products used for care):
Head (unusual headaches frequency of headaches head injury dizziness syncope or vertigo):
Eyes (difficulty or change in vision decreased acuity blurring blind spots eye pain diplopia redness or swelling watering or discharge glaucoma or cataracts):
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):
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):
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):
Health Promotion (Daily dental care brushing flossing. Use of prosthetics bridges dentures. Last dental exam/check-up.):
Neck (pain limitation of motion lumps or swelling enlarged or tender lymph nodes goiter):
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):
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):
Health Promotion (last blood glucose test and result diet):
Breast and Axilla (pain lump tenderness swelling rash nipple discharge any breast surgery):
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.):
Health Promotion (last chest x-ray smoking cessation):
Cardiac System (history of cardiac disease MI atherosclerosis arteriosclerosis chest pain angina):
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):
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):
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):
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):
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):
Health Promotion (methods used to prevent urinary tract infections use of feminine hygiene products Kegelexercises):
Male Genital System (penis or testicular pain sores or lesions penile discharge lumps hernia):
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):
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):
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.
One wellness nursing diagnosis with rationale for choice of this diagnosis.
One risk for nursing diagnosis based on the health screening with rationale for choice of this diagnosis.
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