Health Screening and History of an Adolescent Client

Biographical Data

Financial Status: ( Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?)

Depends on the parents/guardian for finances

Source and Reliability of Informant:

Patient’s word since there is no past history regarding the condition

Past Use of Health Care System and Health Seeking Behaviors:

No past history regarding the condition

Present Health or History of Present Illness:

The patient feels a painful lump in her left breast. This condition has not been there in the past

Past Health History

General Health : (Patient’s own words)

There has not been a major health concern in the past. The condition started three weeks ago, and this is the first time she is seeking healthcare assistance.

Allergies: (include food and medication allergies)  

Fatty foods

Reaction:

Swollen face and rushes all over the body which disappears after a day or two.

Current Medications:

N/A

Last Exam Date:

N/A

Immunizations:

N/A

Childhood Illnesses:

Running nose in winter and nose bleeding during summer

Serious or Chronic Illnesses:

N/A

Past Accidents or Injuries:

N/A

Past Hospitalizations:

N/A

Past Operations:

N/A

Family History

(Specify which family member is affected.)

Obstetric History (if applicable)

Course of Pregnancy (length of pregnancy, delivery date, method of delivery, length of labor, complications, baby’s weight, baby’s condition):

N/A

Well Young Adult Behavioral Health History Screening

Socio-Demographic Content and Questions:

What organizations or activities (community, school, church, lodge, social, professional, academic, sports) are you involved in? 

School drama club

How would you describe your community?

The community is generous supportive and involving in the communal activities

Hobbies, skills, interests, recreational activities?

Socializing, watching movies, swimming and hanging out.

Military service: No 

If yes, overseas assignment? N/A

Close friends or family members who have died within past 2 years?

2

Number of relatives or close friends in this area?

8

Marital status: Single___3___ Married___2_____Divorced_____0____Separated___0______  In serious relationship__3______ Length of time___0______

Environmental Content and Questions:

Do you live alone? No

When did you last move? N/A

Describe your living situation? I leave comfortably with my parents in our home house

Number of years of education completed?

17

Occupation? N/A

If employed, how long?

Are you satisfied with this work situation?

Do you consider your work dangerous or risky?

Is your work stressful?

Over the past 2 years have you felt depressed or hopeless? 

Yes. After the death of a close friend eight months ago through a road accident

Biophysical Content and Questions

Have you smoked cigarettes? No

How much? N/A

Less than ½ pack per day_N/A____ About 1 pack per day?__N/A____ More than 1 and ½ packs per day___N/A___

Are you smoking now? No

Length of time smoking? _______N/A_______

Have you ever smoked illicit drugs? No

If yes, for how long? ____N/A_______ Do you smoke these now? No 

Do you ingest illicit drugs of any kind? No

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 ):

Current weight is 54. Having lost 2kg over a period of two years due to fatigue 

Skin (history of skin disease, pigment or color change, change in mole, excessive dryness or moisture, pruritis, excessive bruising, rash or lesion):

Observation : the skin seems normal

Patient’s word : Skin only develops rashes if I consume mutton 

Health Promotion (Sun exposure? Skin care products?):

Avoid consuming fatty foods.

Hair (recent loss or change in texture):

Observation: no effect on hair 

Patient’s words: no changes

Health Promotion (method of self-care, products used for care) : 

N/A

Nails (change in color, shape, brittleness):

Observation: the nails in normal shapes and color

Patient’s words: no nail changes has occurred

Health Promotion (method of self-care, products used for care):

N/A

Head (unusual headaches, frequency of headaches, head injury, dizziness, syncope or vertigo):

Experience frequent short-lived headaches now and then.

Eyes (difficulty or change in vision, decreased acuity, blurring, blind spots, eye pain, diplopia, redness or swelling, watering or discharge, glaucoma or cataracts):

Observation: No change in color, no swelling, and no discharge.

Patient’s words: eyes not affected in any way

Health Promotion (wears glasses or contacts and reason, last vision check, last glaucoma check, sun protection):

N/A

Ears (earaches, infections, discharge and its characteristics, tinnitus or vertigo):

Observation: No discharge. Nothing unusual observed.

Patient’s words: Ears not affected

Health Promotion (hearing loss, hearing aid use, environmental noise exposure, methods for cleaning ears):

N/A

Nose and Sinuses (discharge and its characteristics, frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, seasonal allergies, change in sense of smell):

Observation: No discharge, pain or nosebleeds.

Patient’s words: Develop running thin clear nasal discharge during winters and regularly nosebleed in summers

Health Promotion (methods for cleaning nose):

Uses a handkerchief soaked in warm water to wipe the nose

Mouth and Throat (mouth pain, sore throat, bleeding gums, toothache, lesions in mouth, tongue, or throat, dysphagia, hoarseness, tonsillectomy, alteration in taste):

Observation: no bleeding gums, no lesions in mouth or tongue. The mouth seems normal.

Patient’s words: no effect felt in the throat or mouth

Health Promotion (Daily dental care – brushing, flossing. Use of prosthetics – bridges, dentures. Last dental exam/check-up.):

N/A

Neck (pain, limitation of motion, lumps or swelling, enlarged or tender lymph nodes, goiter):

Observation: no pain, movement limitation or swellings on the neck.

Patient’s words: no effect on the neck

Neurologic System (history of seizure disorder, syncopal episodes, CVA, motor function or coordination disorders/abnormalities, paresthesia, mood change, depression, memory disorder, history of mental health disorders):

Observation: no mood change or memory loss depicted

Patient’s words: no history regarding neurologic disorders or mental health disorder.

Health Promotion (activities to stimulate thinking, exam related to mood changes/depression):

N/A

Endocrine System (history of diabetes or insulin resistance, history of thyroid disease, intolerance to heat or cold):

Patient’s words: no history of diabetes or thyroid diseases. Extreme cold causes running nose and heat causing nose bleeding.

Health Promotion (last blood glucose test and result, diet):

N/A

Breast and Axilla (pain, lump, tenderness, swelling, rash, nipple discharge, any breast surgery):

Observation: one can feel a small unusual lump on the left side breast.no rushes and no nipple discharge.

Patient’s words: There is a painful lump in my left breast that has lasted for nearly two months now. No previous surgery on the gland.

Health Promotion (performs breast self-exam – both male and female, last mammogram and results, use of self-care products):

This is the first time she’s visited a healthcare facility concerning the illness

Respiratory System (History of lung disease, smoking, chest pain with breathing, wheezing, shortness of breath, cough – productive or nonproductive. Sputum – color and amount. Hemoptysis, toxin or pollution exposure.):

Observation: no sign of being a smoker. No wheezing, shortness of breath or coughing.

Patient’s words: no history of lung disease or chest pain when breathing. No effect felt in the respiratory system.

Health Promotion (last chest x-ray, smoking cessation):

N/A

Cardiac System (history of cardiac disease, MI, atherosclerosis, arteriosclerosis, chest pain, angina):

Observation. The heart beats are normal

Patient’s words: no history of cardiac disease or chest pain regarding the condition.

Health Promotion (last cardiac exam):

N/A

Peripheral Vascular System (coldness, numbness, tingling, swelling of legs/ankles, discoloration of hands/feet, varicose veins, intermittent claudication, thrombophlebitis or ulcers):

Observation: No swelling of legs or discoloration of either feet or hands

Patient’s words: no abnormalities experienced

Health Promotion (avoid crossing legs, avoid sitting/standing for long lengths of time, promote wearing of support hose):

N/A

Hematologic System (bleeding tendency of skin or mucous membranes, excessive bruising, swelling of lymph nodes, blood transfusion and any reactions, exposure to toxic agents or radiation):

Observation. No excessive bruises

Patient’s words: no bleeding tendency of skin and mucus membrane, no past blood transfusion and no exposure to toxic radiations.

Health Promotion (use of standard precautions when exposed to blood/body fluids):

N/A

Gastrointestinal System (appetite, food intolerance, dysphagia, heartburn, indigestion, pain [with eating or other], pyrosis, nausea, vomiting, history of abdominal disease, gastric ulcers, flatulence, bowel movement frequency, change in stool [color, consistency], diarrhea, constipation, hemorrhoids, rectal bleeding):

Patient’s words: No history of the abdominal disease and gastric ulcers. No problem with the gastrointestinal system

Health Promotion (nutrition – quality/quantity of diet; use of antacids/laxatives):

N/A

Musculoskeletal System (history of arthritis, joint pain, stiffness, swelling, deformity, limitation of motion, pain, cramps or weakness):

Observation: no visible deformity or limitation of motion.

Patient’s words: No history of arthritis, joint pain or general musculoskeletal system weakness

Health Promotion (mobility aids used, exercises, walking, effect of limited range of motion):

N/A

Urinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or straining, urine color, narrowed stream, incontinence; history of urinary disease; pain in flank, groin, suprapubic region or low back):

Patient’s word: The urinary system is functioning normally with no recent changes.

Health Promotion (methods used to prevent urinary tract infections, use of feminine hygiene products, Kegel exercises):

N/A

Male Genital System (penis or testicular pain, sores or lesions, penile discharge, lumps, hernia):

N/A

Health Promotion (performs testicular self-exam):

N/A

Female Genital System (menstrual history, age of first menses, last menstrual cycle, frequency of cycles, premenstrual pain, vaginal itching, discharge, premenopausal symptoms, age at menopause, postmenopausal bleeding):

Patient’s words: The cycle started at the age of 12 years and always lasted for 28 days until I got a contraceptive injection at the age of 19 years. I used to experience premenstrual pain and vaginal itching which disappeared after the injection.

Health Promotion (last gynecological checkup, pap-smear and results, use of feminine hygiene products):

Used sanitary towels and proper cleaning of the genitals with disinfected water.

Sexual Health (presently involved in relationship involving intercourse or other sexual activity, aspects of sex satisfactory, use of contraceptive, is relationship monogamous, history of STD):

Patient’s words: Have a boyfriend and is sexually active with who am satisfied with sexually. I do use Depo-Provera injection as a contraceptive measure. No STD history.

Health Promotion (safe-sex practices):

We practice monogamous relationship as a safe-sex measure