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: Terri Serna Date: July 31, 2017 Biographical Data Patient/Client Initials: JAS Phone No: 951-850-0450 Address: 222 Glenmont Circle, Hemet Ca 92544 Birth Date: March 25, 2006 Age:11 Sex: Male Birthplace: Riverside, CA
Marital Status: Single Race/Ethnic Origin: White/Hispanic Occupation: Student Employer: N/A Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?) Pt lives with his mom, stepdad and little sister. Is not...