Screening of an Young or Small Adult Client
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Biographical Data
Patient/Client Initials: CLW
Mobile phone No: [HIDDEN]
123 Anywhere Lane, A lot of Town, A lot of State 00000
Birth Date: goal -09-90
Age
Sex: girl
Birthplace: A few State
Marital Status: n/a
Race/Ethnic Origin: African America
Occupation: n/a
Employer: pupil
Financial Position: This individual is coming from a low-income family whose father is definitely deceased and mother is usually disabled obtaining only minimal income. The family will get food rubber stamps and has Medicaid benefits.
Source and Reliability of Informant: The 14-year-old girl is accompanied by her cousin who is a reputable source of details.
Past Usage of Health Care System and Overall health Seeking Behaviors: The child is not seen regularly by a pediatrician during her childhood. Vaccinations are not up-to-date.
Present Overall health or History of Present Health issues:
This 14-year-old female gives with obesity.
Past Well being History
The health: My abdomen does not feel great. I just don’t feel good. My own teeth injure and my head hurts.
Allergy symptoms: (include food and medication allergies) No well-known allergies
Response: n/a
Current Medications: Affected person states the lady takes tums quite frequently for stomach upset.
Last Examination Date: Affected person was reviewed 1 year in the past at the er with cascarrabias bowels.
Immunizations: Not up dated.
Childhood Ailments: This 14-year-old female and her cousin report no serious the child years illnesses though she has acquired pneumonia on several events.
Serious or Chronic Health problems:
This 14-year-old female can be overweight and obese.
0/
Past Wellness Screening The 14-year-old females father was an alcoholic, suffered a stroke plus the child’s mother has osteoarthritis, diabetes, cardiovascular disease, and heart disease.
Past Injuries or Accidents:
n/a
Previous Hospitalizations:
Zero inpatient vestibule
Past Functions:
n/a
Family History
(Specify which will family member can be affected. )
Alcoholism (ETOH use/abuse): Dad
Allergies: n/a
Arthritis: Mom
Asthma: Mom
Blood Disorders: n/a
Cancer of the breast: n/a
Tumor (Other): n/a
Cerebral Vascular Accident (Stroke): Father
Diabetes: Mother
Heart problems: Mother
Hypertension: Mother
Immunological Disorders: n/a
Kidney Disease: Father
Mental Illness: n/a
Neurological Disorder: n/a
Unhealthy weight: Mother and Father
Seizure Disorder: n/a
Tuberculosis: n/a
Obstetric History (if applicable)
Gravida:
Term:
Preterm:
Miscarriage/Abortions:
Course of Pregnancy (length of pregnancy, delivery date, approach to delivery, period of labor, issues, baby’s excess weight, baby’s condition):
Well Small Adult Behavioral Health Background Screening
Socio-Demographic Content and Questions:
What organizations or activities (community, school, church, lodge, social, professional, academics, sports) will you be involved in? The patient attends cathedral on Sunday. No various other community activities.
How might you describe your community? This kind of female referred to her community as poor and boring.
Hobbies, expertise, interests
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