WHAT ORGANIZATIONS OR ACTIVITIES (COMMUNITY, SCHOOL, CHURCH, LODGE, SOCIAL, PROFESSIONAL, ACADEMIC, SPORTS) ARE YOU INVOLVED IN?

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)

Reaction:

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)

Tuberculosis:
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?

Occupation?
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_________________

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 ):

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

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

Hair (recent loss or change in texture):

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

Nails (change in color, shape, brittleness):

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

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