Achieving Better Coping Skills, LLC -
INITIAL HEALTH CARE
24 HOUR YOUTH CURSORY
R6-5-7438(E), R6-5-7452(B-C)
THIS RECORD SHOULD BE KEPT ON FILE AT THE FACILITY AND COMPLETED THE FIRST DAY OF YOUTH ARRIVAL.
LOCATION
Please Select
ASHER HOUSE
SHOULDER'S HOUSE
YOUTH NAME
*
Mercy Care DCS CHP Member ID No.
previously known as Participant ID (PI No.) or CMDP
INTAKE DATE
*
-
Month
-
Day
Year
Date
DATE OF BIRTH
-
Month
-
Day
Year
Date Picker Icon
PLEASE CHECK ALL OF THE FOLLOWING THAT APPLY TO THE NEW YOUTH:
Type a question
Sexually Active
Venereal Diseases
Burning or itching sensations
Physical Injuries
Cuts or scratches
Tattoos or piercing
Difficulty breathing
Measles or Chicken Pox
Previous surgeries
Previous hospitalizations
Food Allergies
Household Allergies
Medication Allergies
Seasonal Allergies
Substance drug abuse
Drinks Alcohol
Any Communicable Diseases
Any Current Colds/Flus
Bed Bugs
Visible Rash/Redness
Currently Under Influence
Please explain in specific details for ALL ABOVE CHECKED ITEMS or COMMENTS
MEDICATIONS CURRENTLY TAKING
VISION | HEARING ASSESSMENT
*
POOR
GOOD
VISION
HEARING
POOR VISION ASSISTANCE (Select One)
Please Select
Glasses
Contacts
None
HEARING AID NEEDED
Yes
No
Able to participate in sports & other strenuous activities
*
YES
NO
Other
Developmental History Provided
Yes (If YES, please explain below)
No
Developmental History
STAFF NAME
*
DATE
-
Month
-
Day
Year
Date
Staff Signature
*
Print Form
Submit
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