Health History and Screening of an Adolescent or Young Adult Client

2425 Words Feb 3rd, 2014 10 Pages
Health History and Screening of an Adolescent or Young Adult Client

Student Name:
Date: January 26, 2014
Biographical Data
Patient/Client Initials: CB
Phone No: 602-388-1612
Address: 115 W. Coronodo Road, Phoenix, AZ 85003
Birth Date: 12/05/98
Age: 15
Sex: M
Birthplace: Phoenix
Marital Status: Single
Race/Ethnic Origin: White
Occupation: Student
Employer: N/A
Financial Status:
Aetna Health Insurance

Source and Reliability of Informant: Self – CB and mother MB

Past Use of Health Care System and Health Seeking Behaviors:
Fracture of left tibia status post skateboard accident (06/2012)
Asthma Attack (08/2012)

Present Health or History of Present Illness:
…show more content…
No

Biophysical Content and Questions

Have you smoked cigarettes? Yes_______ No___X_____

How much?
Less than ½ pack per day_____ About 1 pack per day?______ More than 1 and ½ packs per day______

Are you smoking now? Yes_______ No____X____ Length of time smoking? ______________

Have you ever smoked illicit drugs? Yes__________ No____X_____

If yes, for how long? ___________ Do you smoke these now? Yes__________ No _____X_____

Do you ingest illicit drugs of any kind? Yes_________ No____X______
If so, what drugs do you use and what is the route of ingestion?_________
How long have you used these drugs _________________

Review of Systems
General Health State:

Patient reports no weight fluctuations. Denies fatigue, malaise, weakness, sweats, night sweats and chills. Patient reports mild left leg weakness secondary to left tibia fracture June 2012, but ambulates well and is able to be active in school sports, hiking, biking, and swimming. Patient reports working on building strength in left leg through sports and recreational activities. Patient reports asthmatic exacerbations with exercise. Patient reports trying to build lung capacity by running and swimming which exacerbates his asthmatic condition and uses inhalers.

Skin:

Patient denies history of skin disease. Reports two serious sun burns while swimming and not re-applying sun screen. Reports occasional dryness of skin during the winter. Denies any
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