Health Screening and History of an Adolescent or Young Adult Client (A Direct Care Experience)

Health Screening and History of an Adolescent or Young Adult Client (A Direct Care Experience)


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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.

While APA format is not required for the body of this assignment, solid academic writing is expected and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.


The screening assignment worksheet is on next page and must be cut and pasted as a response document on its own. The Grading Rubric is also copied and pasted below it as a guide

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_________________




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):


Head (unusual headaches, frequency of headaches, head injury, dizziness, syncope or vertigo):



Eyes (difficulty or change in vision, decreased acuity, blurring, blind spots, eye pain, diplopia, redness or swelling, watering or discharge, glaucoma or cataracts):


Health Promotion (wears glasses or contacts and reason, last vision check, last glaucoma check, sun protection):


Ears (earaches, infections, discharge and its characteristics, tinnitus or vertigo):



Health Promotion (hearing loss, hearing aid use, environmental noise exposure, methods for cleaning ears):


Nose and Sinuses (discharge and its characteristics, frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, seasonal allergies, change in sense of smell):


Health Promotion (methods for cleaning nose):


Mouth and Throat (mouth pain, sore throat, bleeding gums, toothache, lesions in mouth, tongue, or throat, dysphagia, hoarseness, tonsillectomy, alteration in taste):


Health Promotion (Daily dental care – brushing, flossing. Use of prosthetics – bridges, dentures. Last dental exam/check-up.):


Neck (pain, limitation of motion, lumps or swelling, enlarged or tender lymph nodes, goiter):



Neurologic System (history of seizure disorder, syncopal episodes, CVA, motor function or coordination disorders/abnormalities, paresthesia, mood change, depression, memory disorder, history of mental health disorders):


Health Promotion (activities to stimulate thinking, exam related to mood changes/depression):


Endocrine System (history of diabetes or insulin resistance, history of thyroid disease, intolerance to heat or cold):


Health Promotion (last blood glucose test and result, diet):


Breast and Axilla (pain, lump, tenderness, swelling, rash, nipple discharge, any breast surgery):


Health Promotion (performs breast self-exam – both male and female, last mammogram and results, use of self-care products):


Respiratory System (History of lung disease, smoking, chest pain with breathing, wheezing, shortness of breath, cough – productive or nonproductive. Sputum – color and amount. Hemoptysis, toxin or pollution exposure.):


Health Promotion (last chest x-ray, smoking cessation):


Cardiac System (history of cardiac disease, MI, atherosclerosis, arteriosclerosis, chest pain, angina):


Health Promotion (last cardiac exam):


Peripheral Vascular System (coldness, numbness, tingling, swelling of legs/ankles, discoloration of hands/feet, varicose veins, intermittent claudication, thrombophlebitis or  ulcers):


Health Promotion (avoid crossing legs, avoid sitting/standing for long lengths of time, promote wearing of support hose):


Hematologic System (bleeding tendency of skin or mucous membranes, excessive bruising, swelling of lymph nodes, blood transfusion and any reactions, exposure to toxic agents or radiation):


Health Promotion (use of standard precautions when exposed to blood/body fluids):


Gastrointestinal System (appetite, food intolerance, dysphagia, heartburn, indigestion, pain [with eating or other], pyrosis, nausea, vomiting, history of abdominal disease, gastric ulcers, flatulence, bowel movement frequency, change in stool [color, consistency], diarrhea, constipation, hemorrhoids, rectal bleeding):


Health Promotion (nutrition – quality/quantity of diet; use of antacids/laxatives):


Musculoskeletal System (history of arthritis, joint pain, stiffness, swelling, deformity, limitation of motion, pain, cramps or weakness):


Health Promotion (mobility aids used, exercises, walking, effect of limited range of motion):


Urinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or straining, urine color, narrowed stream, incontinence; history of urinary disease; pain in flank, groin, suprapubic region or low back):


Health Promotion (methods used to prevent urinary tract infections, use of feminine hygiene products, Kegelexercises):


Male Genital System (penis or testicular pain, sores or lesions, penile discharge, lumps, hernia):


Health Promotion (performs testicular self-exam):


Female Genital System (menstrual history, age of first menses, last menstrual cycle, frequency of cycles, premenstrual pain, vaginal itching, discharge, premenopausal symptoms, age at menopause, postmenopausal bleeding):


Health Promotion (last gynecological checkup, pap-smear and results, use of feminine hygiene products):


Sexual Health (presently involved in relationship involving intercourse or other sexual activity, aspects of sex satisfactory, use of contraceptive, is relationship monogamous, history of STD):


Health Promotion (safe-sex practices):


Nursing Diagnoses:


Based on this health history and health screening, identify three nursing diagnoses that would be applicable for this client as well as your rationale for your selection of each nursing diagnosis. Include:




One “actual” nursing diagnosis with rationale for choice of this diagnosis.



One wellness nursing diagnosis with rationale for choice of this diagnosis.



One “risk for” nursing diagnosis based on the health screening with rationale for choice of this diagnosis.














20.0 %Include All Components of the Health Screening and Health History (Biographical Data, Past Health History, Family History, Review of Systems)

Provides all components of the health screening and history in extensive detail and relates information to the diagnoses and integrates into treatment plan.

30.0 %Develop Actual Nursing, Wellness, and ?Risk For? diagnoses for the Client Based on Health History and Screening

Interrelates complete and accurate nursing diagnoses (Actual, Wellness, and Risk For), provides rationale based upon the information collected in the health screening and history, and review of systems, and integrates each diagnosis into a recommended wellness plan for the patient.

20.0 %Wellness Plan

Provides all components of the wellness plan in extensive detail and relates information to the diagnoses.

10.0 %Use Appropriate Medical Acronyms and Abbreviations

Medical acronyms and abbreviations are sophisticated and used appropriately

10.0 %Organization and Effectiveness 10.0 %Mechanics of Writing (Includes spelling, punctuation, grammar, and language use)

Writer is clearly in command of standard, written, academic English.

10.0 %Research Citations (In-text citations for paraphrasing and direct quotes, and reference page listing and formatting, as appropriate to assignment)

In-text citations and a reference page are complete. The documentation of cited sources is free of error.




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