Health History and Screeening

Health History and Screening of an Adolescent or Young Adult Client

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Student Name: Jennifer R Romero | Date: 2/9/2014 |

Biographical Data |

Patient/Client Initials: JFM | Phone No: 562-761-9145 |

Address: 11004 Kentucky Ave Whittier, CA 90603 |

Birth Date: 3/23/1993 | Age: 20 | Sex: Female |

Birthplace: Whittier CA | Marital Status: Single |

Race/Ethnic Origin: Hispanic |

Occupation: Full Time College Student at Cal State Los Angeles | Employer: Caregiver for little brother w/ Autism |

Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?) * She lives with Both Parents and is dependent under mothers insurance plan. Both parents financially support her. |

Source and Reliability of Informant: * Patient and mother are the Reliability of Source. Pt. is A/Ox4 |

Past Use of Health Care System and Health Seeking Behaviors: * None |

Present Health or History of Present Illness: * Abdominal/pelvic pain intense cramps, and abnormal bleeding with menstrual cycle. |

Past Health History |

General Health: (Patient’s own words) * ‘Good exercises 3-4 x’s/week” |

Allergies: (include food and medication allergies) * NKDA | Reaction: * N/A |

Current Medications: * Percocet 5/325 1 Tab PO q 4-6 hrs. PRN pain. * PRN Benadryl and Claritin for Seasonal Allergy. |

Last Exam Date: * 1/14/2014 | Immunizations: * IUTD= Immunizations up to date |

Childhood Illnesses: * NONE |

Serious or Chronic Illnesses: * NONE |

Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below) * Yearly Physical Exam with Pap and Breast exam |

Past Accidents or Injuries: * NONE |

Past Hospitalizations: * ER visits for abdominal/pelvic pain,...