Nurse

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Submitted By Sandra2
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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: Christan R | Date: 10/02/2015 | Biographical Data | Patient/Client Initials: CR | Phone No: 555 5890 | Address: 123 Nostreet Cr | Birth Date: 07/18/1998 | Age: 17 | Sex: M | Birthplace: Alaska | Marital Status: Single | Race/Ethnic Origin: White | Occupation: Student | Employer: Bahama Bucks | 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) | Past Accidents or Injuries: | Past Hospitalizations: | Past Operations: | Family History(Specify which family member is affected.) | Alcoholism (ETOH use/abuse): | Allergies: | Arthritis: | Asthma: | Blood Disorders: | Breast Cancer: | Cancer (Other): | Cerebral Vascular Accident (Stroke): | Diabetes: | Heart Disease: | High Blood Pressure: | Immunological Disorders: | Kidney Disease: | Mental Illness: | Neurological Disorder: | Obesity: | Seizure Disorder: | Tuberculosis: | Obstetric History (if applicable) | Gravida: | Term: | Preterm: |…...

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