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: Jennifer R Romero Date: 2/9/2014 Biographical Data Patient/Client Initials: JFM Phone No: 562-761-9145 Address: 11004 Kentucky Ave Whittier, CA 90603 Birth Date: 3/23/1993 Age: 20 Sex: Female Birthplace: Whittier CA Marital Status: Single Race/Ethnic Origin: Hispanic Occupation: Full Time College Student at Cal State Los Angeles Employer: Caregiver for little brother w/ Autism Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?)  She lives with Both Parents and is dependent under mothers insurance plan. Both parents financially support her. Source and Reliability of Informant:  Patient and mother are the Reliability of Source. Pt. is A/Ox4 Past Use of Health Care System and Health Seeking Behaviors:  None Present Health or History of Present Illness:  Abdominal/pelvic pain intense cramps, and abnormal bleeding with menstrual cycle. Past Health History General Health: (Patient’s own words)  ‘Good exercises 3-4 x’s/week” Allergies: (include food and medication allergies)  NKDA Reaction:  N/A Current Medications:  Percocet 5/325 1 Tab PO q 4-6 hrs. PRN pain.  PRN Benadryl and Claritin for Seasonal Allergy. © 2011. Grand Canyon University. All Rights Reserved.