DEPARTMENT OF JUVENILE JUSTICE AND DELINQUENCY PREVENTION

Document Sample
DEPARTMENT OF JUVENILE JUSTICE AND DELINQUENCY PREVENTION Powered By Docstoc
					                                             DEPARTMENT OF JUVENILE JUSTICE
                                              AND DELINQUENCY PREVENTION
                                                                                                                         Confidential
                                             MALE INTAKE HEALTH ASSESSMENT
      Juvenile Information Label
      Name:                                           DOB:
      SS #:                                           Race:
      DOE:                                            Gender: Male
      Facility:
I. IMMUNIZATIONS
The North Carolina Immunization Record (NCIR) is placed in the juvenile’s medical record.         Yes    No
Refer to this record to determine if the juvenile’s immunizations are current according to applicable law and in
accordance with the recommended schedule. All immunizations are to be recorded in the NCIR



II. HISTORY OF PRESENT ILLNESSES/INJURIES
Current illnesses/injuries (Quality–Severity-Modifying Factors–Timing–Duration-Associated Signs or Symptoms- Chronic Interactive Conditions




Allergies
Medication: (List the medication)                                                                         Reaction:


Insect: (Name the insect)                                                                                  Reaction:


Food: (Name the food)                                                                                      Reaction:


Asthma: (List the offending antigen, i.e., pollen, dust, smoke, animal dander)                             Reaction:



Present medications: (List dosage, times of administration)




YC/M 003 Male Intake Health Assessment                                                                                         Page 1 of 6
Form structure last revised December 2009
Department of Juvenile Justice and Delinquency Prevention
III. PAST MEDICAL ILLNESSES                                                      Juvenile’s Name:
Past significant illnesses/injuries/surgeries:




Previous hospitalizations (including psychiatric):




Mental health:




Dental (last exam):




IV. SOCIAL HISTORY
Alcohol/Tobacco/Illegal Drug Use (types used; mode of use; amounts; frequency; date/time of last use; problems
resulting from ceasing use): Do you use drugs, alcohol or tobacco?     Yes           No
If yes, list:
Type used                                          Mode of use
Amount used                                        Frequency of use
Date or time of last use
Have you had a history of problems that may have occurred after ceasing use (e.g. convulsions)?  Yes No
Type of problem:
Type used                                         Mode of use
Amount used                                       Frequency of use
Date or time of last use
Have you had a history of problems that may have occurred after ceasing use (e.g. convulsions)?      Yes        No
Type of problem:
List additional types on next page



YC/M 003 Male Intake Health Assessment                                                            Page 2 of 6
Form structure last revised December 2009
Department of Juvenile Justice and Delinquency Prevention
IV. SOCIAL HISTORY CONTINUED                                             Juvenile’s Name:
Alcohol/Tobacco/Illegal Drug Use continued:
Type used                                         Mode of use
Amount used                                       Frequency of use
Date or time of last use
Have you had a history of problems that may have occurred after ceasing use (e.g. convulsions)?                      Yes        No
Type of problem:
Type used                                         Mode of use
Amount used                                       Frequency of use
Date or time of last use
Have you had a history of problems that may have occurred after ceasing use (e.g. convulsions)?                      Yes        No
Type of problem:


Reproductive History

a. Currently sexually active             Yes                No

b. Contraception used:                   Yes                No        Method:

e. Multiple sex partners:                Yes                No        How many?

c. Treated in past for STD               Yes                No
If yes, list:




V. FAMILY HISTORY (Tuberculosis, Chronic diseases, Mental Illness, Inherited diseases, Cancer, Childhood deaths, Alcoholism):
a. Mother




b. Father




c. Siblings




YC/M 003 Male Intake Health Assessment                                                                           Page 3 of 6
Form structure last revised December 2009
Department of Juvenile Justice and Delinquency Prevention
VI. REVIEW OF SYSTEMS (check Yes or No)                                               Juvenile’s Name:
         Acne                            Yes      No        Stomach aches                                     Yes        No
         Rashes                          Yes      No        Nausea/Vomiting                                   Yes        No
         Headaches                       Yes      No        Constipation                                      Yes        No
         Hearing Problem                 Yes      No        Diarrhea                                          Yes        No
         Ear Aches                       Yes      No        Kidney Diseases                                   Yes        No
         Vision Problem                  Yes      No        Trouble Urinating                                 Yes        No
         Glasses                         Yes      No        Bedwetting                                        Yes        No
         Contacts                        Yes      No        Sleep Problems                                    Yes        No
         Toothache                       Yes      No        Gonorrhea                                         Yes        No
         Braces                          Yes      No        Chlamydia                                         Yes        No
         Nose Bleeds                     Yes      No        HIV/AIDS                                          Yes        No
         Speech Problems                 Yes      No        Hepatitis B                                       Yes        No
         Fainting Spells                 Yes      No        Other STDs                                        Yes        No
         Seizures/Epilepsy               Yes      No        Crabs                                             Yes        No
         Asthma                          Yes      No        Lice                                              Yes        No
         Diabetes                        Yes      No        Mononucleosis                                     Yes        No
         High Blood Pressure             Yes      No        Depression                                        Yes        No
         Heart Problem                   Yes      No        Suicide                                           Yes        No
                                                            Other                                             Yes        No
Explanation of Positive Responses:




VII. RISK OF DANGER SCREENING
Have you ever tried to hurt or kill yourself?                                   Yes            No
If so, what did you do?
When did this happen?
Then what happened?


Did you have to go to a hospital?                                               Yes            No
Did you have to go to talk to a counselor about it?                             Yes            No

Have you had any thoughts of hurting yourself lately?                           Yes            No
If so, what have you been thinking about?

Do you have a plan?                                                             Yes            No
What is it?

Have you had any thoughts of hurting anyone else?                               Yes            No
If so, who?
How?
When?




Nurse’s Signature                                                                     Date
                                                                                                                    AM or PM
                                                                                                    Time             (Circle)


YC/M 003 Male Intake Health Assessment                                                                     Page 4 of 6
Form structure last revised December 2009
Department of Juvenile Justice and Delinquency Prevention
VIII. BODY CHECK/INJURY VERIFICATION                                                    Juvenile’s Name:

Race:      _______________ Height:                               Weight:                ___ Hair color:
Eye color:

Circle Y for Yes or N for No
1. Scrapes/Abrasions                           Y            N   7. Lesions                     Y      N
2. Birthmark                                   Y            N   8. Rashes                      Y      N
3. Bruises                                     Y            N   9. Scars                       Y      N
4. Scratches/Lacerations                       Y            N   10. Tattoos                    Y      N
5. Deformities                                 Y            N   11. Prosthesis                 Y      N
6. Pierced ears/nose/body parts                Y            N

If a yes response is indicated, mark the body figure with the appropriate number in the area the abnormality is
located. Add a description of these in the Comments section. Describe the color of all bruises and the color, length
and width of all scars.




Comments:

Nurse’s Signature                                                                Date

                                                                                         AM or PM
                                                                                 Time   (Circle)




YC/M 003 Male Intake Health Assessment                                                                Page 5 of 6
Form structure last revised December 2009
Department of Juvenile Justice and Delinquency Prevention
IX. GENERAL APPEARANCE AND OBSERVATIONS                                      Juvenile’s Name:
(Check all boxes that apply)
Physical Appearance:         disheveled                                          neat

Mood:              Juvenile Seems:                 calm        elated           angry
                                                   anxious      sad              irritable

Affect:            Juvenile Seems:                 normal       blunted          constricted
                                                   flat         labile           inappropriate

Thought:           Juvenile Feels/Seems:           good vocabulary               speaks fluently
                                                   good fund of knowledge        associations seem loose
                                                   thoughts seem to race         seems very distractible
                                                   logical

Behavior (tremor; sweating, conduct, state of consciousness, mental status):




Deformities: (list all deformities and write a brief description)




Skin (i.e., abrasions, bruises, laceration, scars, deformities, needle marks or other indications of drug abuse - Refer
to above body check.)




X. MEDICAL DISPOSITION (Check one)
    general population
    general population with appropriate referral to health care service
    referral to appropriate health care service for emergency treatment



Nurse’s Signature                                                            Date
                                                                                                     AM or PM
                                                                                        Time         (Circle)


YC/M 003 Male Intake Health Assessment                                                               Page 6 of 6
Form structure last revised December 2009
Department of Juvenile Justice and Delinquency Prevention

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:5
posted:7/5/2011
language:English
pages:6