ACHIEVING BETTER COPING SKILLS, LLC
YOUTH MEDICAL HISTORY
R6-5-7455(1, 3, 4)
THIS RECORD SHOULD BE KEPT ON FILE AT THE FACILITY
Client"s past medical history upon arrival
LOCATION
Please Select
ASHER HOUSE
SHOULDER'S HOUSE
YOUTH NAME
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Did you receive a copy of youths Immunization Records (If yes, please attach)
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Yes
No
List any illnesses or serious injuries
Any Surgeries?
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No
Yes (Please explain)
Any Known Allergies?
No
Yes (Please explain)
Any Adverse Drug Reactions?
No
Yes (Please explain)
Explain Client"s past medical history:
Please list any history of alcohol and/or substance abuse habits. Include any treatments:
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Any Documentation (Prescriptions) of medication(s) received with child at time of admisssion
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COMPLETED BY (STAFF NAME)
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Staff Signature
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