Health Screen and Assessment

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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: Leigh Hinson | Date: 10/19/2015 | Biographical Data | Patient/Client Initials: ECN | Phone No: 910-654-1107 | Address: 6893 Princess Ann Rd. Evergreen NC 28438 | Birth Date:7-20-1999 | Age: 16 | Sex:F | Birthplace: Whiteville, NC | Marital Status:Single | Race/Ethnic Origin: White | Occupation: Cashier | Employer: Food Lion | Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance?
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10 Occupation? If employed, how long? 6 months. Are you satisfied with this work situation? Yes Do you consider your work dangerous or risky? No Is your work stressful? No Over the past 2 years have you felt depressed or hopeless? 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? _____N/A_________ Have you ever smoked illicit drugs? Yes__________ No____X_____ If yes, for how long? ___N/A________ Do you smoke these now? Yes__________ No _________ 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?__N/A_______How long have you used these drugs _____N/A____________ | 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 ): She currently weighs 110lbs. No weight loss. She is well developed and nourished. No distress. States she has always been healthy, other than occasional constipation. | Skin (history of skin disease, pigment or color change, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash
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