Readiness Essentials™: Wesley Blanco Health History

800 Country Club Road, P.O. Box 2540, Waterbury, CT 06723 | 1.800.749.2427 | SentinelU.com 1

Client: Wesley Blanco Table of Contents

Client Information ……………………………………………………………………………………………………………………. 2

Health History …………………………………………………………………………………………………………………………. 3

New Patient Self-Rated Wellbeing Checklist ……………………………………………………………………………….. 4

Readiness Essentials™: Wesley Blanco Health History

800 Country Club Road, P.O. Box 2540, Waterbury, CT 06723 | 1.800.749.2427 | SentinelU.com 2

Client Information Client Information

Name Age Wesley Blanco 13 years old Race/Ethnicity Language(s) Filipino, White English Sex Assigned at Birth Gender Identity Pronouns Male Non-Binary They/Them Height Weight Marital Status 4’ 11” / 150 cm 88 lb / 40 kg Single Allergies NKA Chief Complaint Guilt, Anxiety

Readiness Essentials™: Wesley Blanco Health History

800 Country Club Road, P.O. Box 2540, Waterbury, CT 06723 | 1.800.749.2427 | SentinelU.com 3

Health History Health History

Past Visit Reasons None Past Medical History None Past Surgical History None Family History Tourette’s syndrome (Father) Systemic lupus erythematosus (Mother) Immunizations Hepatitis B (3-dose series) (18 months old) Measles, mumps, rubella (2-dose series) (5 years

old) Rotavirus RV1 (2-dose series) (4 months old) Varicella (2-dose series) (5 years old) Diptheria, tetanus, & acellular pertussis (5-dose series) (5 years old)

Haemophilus influenzae type b (3-dose series) (12 months old)

Tetanus, diptheria, & acellular pertussis (12 years old)

Inactivated poliovirus (4-dose series) (5 years old)

Pneumococcal conjugate (4-dose series) (15 months old)

Meningococcal (1st of 2 dose series) (12 years old)

Social History Smoking Status: None Smokeless Tobacco: None Alcohol Use: None Drug Use: None Current Diet: Standard American/Filipino Heritage How Often do you Exercise: 5x/week Type Exercise: School PE Wears Seatbelt: Yes Sexually Active: No How Many Sexual Partners: 0 How Many Partners in Lifespan: 0 How Long with Current Partner: N/A Contraception: N/A History of STIs: None Feels Safe at Home: Yes Health Maintenance Last Annual Exam: 6 months ago Vision Problems: No Wears Contacts or Glasses: No Last Eye Exam: 6 months ago Dentist Every Six Months: Yes Brushes/Flosses Daily: Yes Has Trouble Hearing: No Social Determinants of Health Financial Resource Strain: Denies Transportation Needs: Denies Housing Instability: Denies Food Insecurity: Denies

Healthcare.gov Preventative – Health Services

U.S. Department of Health and Human Services – Health Screening

The United States Preventive Services Taskforce

CDC Immunization Schedules

Readiness Essentials™: Wesley Blanco Health History

800 Country Club Road, P.O. Box 2540, Waterbury, CT 06723 | 1.800.749.2427 | SentinelU.com 4

New Patient Self-Rated Wellbeing Checklist New Patient Self Rated Well Being Checklist

Please rate the following items that best describe your experiences over the last 2 weeks. Statement None of

the Time Rarely Some of

the Time Often All of the

Times I feel physically energized and healthy.

X

I engage in regular physical activity or exercise.

X

I can manage stress effectively. X I have a positive outlook on life. X I feel emotionally stable and content. X I have a positive outlook on life. X I feel a sense of purpose and fulfillment in my daily activities.

X

I have a strong support system of family and friends.

X

I have a balanced and nutritious diet. X