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:
Wears a baseball cap occasionally when in the sun. Use of body lotion when skin is dry.

Hair:

Patient denies any recent loss or change of texture of hair.

Health Promotion:

Washes hair daily. Uses moisturizing Head and Shoulder’s shampoo.

Nails:

Patient denies any change in color, shape, or brittleness of nails.

Health Promotion:

Patient cuts own nails when long, usually every 1.5 – 2 weeks.

Head:

Patient rarely has a headache. Use of Tylenol cures headache. No history of head injury, dizziness, syncope or vertigo reported.

Eyes:

Patient has had no change of vision since last eye appointment July 2013. Occasional redness reported from seasonal allergies. Denies blurring, blind spots, eye pain, diplopia, redness or swelling, and watering or discharge. Denies glaucoma or cataracts.

Health Promotion:

Patient reports being nearsighted (myopic) and is currently wearing disposable Acuvue contacts. Has an eye exam annually that includes a glaucoma check, last exam July 2013. Patient wears sunglasses but unsure if they contain UV protection.

Ears:

Patient denies earaches, infections, discharge from ears, tinnitus, and vertigo.

Health Promotion:

Mother reports the use of Murine (ear cleaning solution) every 1 – 2 months. Mother verbalizes understanding that Q-tips are not recommended. Patient reports understanding of keeping music at