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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