Health Screening and History of an Adolescent or Young Adult Client

Benchmark Assignment – Health Screening and History of an Adolescent or Young Adult Client

Order Details/Description

In this assignment, you will be completing a comprehensive health screening and history on a young adult. To complete this assignment, do the following:

Select an adolescent or young adult client on whom to perform a health screening and history. Students who do not work in an acute setting may “practice” these skills with a patient, community member, neighbor, friend, colleague, or loved one.

Complete the “Health History and Screening of an Adolescent or Young Adult Client” worksheet.

Format the write-up in a manner that is easily read, computer-generated, neat, and without spelling errors.

Complete the assignment as outlined on the worksheet, including:

1.Biographical Data

2.Past Health History

3.Family History: Obstetrics History (if applicable) and Well Young Adult Behavioral Health History Screening

4.Review of Systems

5.Include all components of the health history

6.Use correct acronyms or abbreviations when indicated

7.Develop three Nursing Diagnoses for this client based on the health history and screening. Include: one actual nursing diagnosis, one wellness nursing diagnosis, one “Risk For” nursing diagnosis, and your rationale for the choice of each nursing diagnosis for this client.

8.Using the three nursing diagnoses you have identified, develop a wellness plan for the adolescent/young adult client

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:
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: (Patient’s own words)

Allergies: (include food and medication allergies)


Current Medications:

Last Exam Date: Immunizations:

Childhood Illnesses:

Serious or Chronic Illnesses:

Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below)
Past Accidents or Injuries:

Past Hospitalizations:

Past Operations:

Family History
(Specify which family member is affected.)

Alcoholism (ETOH use/abuse):
Blood Disorders:
Breast Cancer:
Cancer (Other):
Cerebral Vascular Accident (Stroke):
Heart Disease:
High Blood Pressure:
Immunological Disorders:
Kidney Disease:
Mental Illness:
Neurological Disorder:
Seizure Disorder:
Obstetric History (if applicable)
Gravida: Term: Preterm: Miscarriage/Abortions:
Course of Pregnancy (length of pregnancy, delivery date, method of delivery, length of labor, complications, baby’s weight, baby’s condition):

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?

How would you describe your community?

Hobbies, skills, interests, recreational activities?

Military service: Yes_______ No_______

If yes, overseas assignment? Yes________ No_________

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

Number of relatives or close friends in this area?

Marital status: Single______ Married________Divorced_________Separated_________
In serious relationship________ Length of time_________

Environmental Content and Questions:

Do you live alone? Yes________ No ________

When did you last move?

Describe your living situation?

Number of years of education completed?


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?

Biophysical Content and Questions

Have you smoked cigarettes? Yes_______ No________

How much?

Less than ½ pack per day_____ About 1 pack per day?______ More than 1 and ½ packs per day______

Are you smoking now? Yes_______ No________ Length of time smoking? ______________

Have you ever smoked illicit drugs? Yes__________ No_________

If yes, for how long? ___________ Do you smoke these now? Yes__________ No __________

Do you ingest illicit drugs of any kind? Yes_________ No__________

If so, what drugs do you use and what is the route of ingestion?_________

How long have you used these drugs _________________