Screening and History Adolescent Assignment Student

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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: Date: Biographical Data Patient/Client Initials: Phone No: Address: Birth Date: Age: Sex: Birthplace:
Marital Status: Race/Ethnic Origin:
Occupation: Employer: Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?)

Source and Reliability of Informant:

Past Use of Health Care System and Health Seeking Behaviors:

Present Health or History of Present Illness:

Past Health History General Health:...

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Published On:
11/24/2016
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nrs434vv10rhealth-screening-and-history-adolescent-assignment-student-45.docx
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