Chamberlain College of Nursing

Family Genetic & Health History Direct Care Alternative Learning Activity

Your Name: Date:

Your Instructor’s Name:

Directions : Complete the information below using either a real or fictitious or adult participant. Should you choose to use an individual for this activity, please remember to maintain privacy by not including any names or personal identifying information.

Please note that the activity can be performed using distance communication modalities.

When complete, please submit the completed activity with the practicum log.

1: Family Genetic History:

Develop a family genetic history that includes, at a minimum, three generations of your chosen adult’s family, including grandparents, parents, and the adult’s generation. If the adult has any children, include them as the fourth generation. **PLEASE NOTE: This activity is to reveal the potential impact of the family’s health on the adult participant. You do not need to identify anyone who is not biologically related to the adult except for a spouse or significant other.

You do not need to use symbols, but instead write brief descriptions for each person. Each description should include the following information: first name, birthdate, death date, occupation, education, primary language, and a health summary, including any medical diagnoses. An example is below.

Complete the family genetic history form below. Indicate if any information is N/A (not applicable) or unknown. Indicate any information the person did not want to disclose by noting “Does not want to disclose.”

Family Member

Description

Paternal grandfather

First and last initials:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary (include cause of death if applicable):

Paternal grandmother

First and last initials:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary (include cause of death if applicable):

Father

First and last initials:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary (include cause of death if applicable):

Father’s siblings (write a brief summary of any significant health issues)

Maternal grandfather

First and last initials:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary (include cause of death if applicable):

Maternal grandmother

First and last initials:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary (include cause of death if applicable):

Mother

First and last initials:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary (include cause of death if applicable):

Mother’s siblings (write a brief summary of any significant health issues)

Adult Participant

First and last initials:

Birthdate:

Occupation:

Education:

Primary language:

Health summary:

Adult participant’s siblings (write a brief summary of any significant health issues)

Adult participant’s spouse/significant other

First and last initials:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary (include cause of death if applicable):

Adult participant’s children (write a summary for each child, up to four children)

Child #1 first and last initials:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary:

Child #2 first and last initials:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary:

Child #3 first and last initials:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary:

Child #4 first and last initials:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary:

2. Health History

BIOGRAPHICAL DATA

Date:

Initials:

Age:

Date of birth:

Birthplace:

Gender:

Marital status:

Race:

Occupation:

Source of information:

Reliability of source of information:

PRESENT HEALTH HISTORY/ILLNESS

Health goals:

MEDICATIONS

Include purpose, dose, duration, frequency, and any desired or undesired effects for each medication.

Prescription medications:

Over-the-counter medications:

Herbals:

PAST HISTORY

Childhood diseases:

Immunizations:

Allergies:

Blood transfusions:

Major illnesses:

Injuries:

Hospitalizations:

Labor and deliveries:

Surgeries:

Use of alcohol:

Use of tobacco:

Use of illicit drugs:

EMOTIONAL HISTORY

Mental, emotional or psychiatric problems:

PSYCHOSOCIAL/ OCCUPATIONAL HISTORY

Occupational history:

Educational level:

Financial background:

ROLES AND RELATIONSHIPS

Significant others:

Support systems:

ETHNICITY AND CULTURE

Ethnicity and culture:

Physical and social characteristics that influence healthcare decisions:

SPIRITUALITY

Beliefs and practices influencing health decisions:

Religious and spiritual needs:

HISTORICAL REVIEW OF SYSTEMS

Skin, hair, nails:

Head, neck, related lymphatics:

Eyes:

Ears, nose, mouth, and throat:

Respiratory:

Breasts and axillae:

Cardiovascular:

Peripheral vascular:

Abdomen:

Urinary:

Reproductive:

Musculoskeletal:

Neurologic:

3. Evaluation of family genetic history

Evaluate the impact of the family’s genetic history on your adult participant’s health. For example, if the adult participant’s mother and both sisters have diabetes, hypertension, or cancer, what might that mean for the adult participant’s future health? (1 paragraph)

4. Evaluation of health history

Evaluate your participant’s health history. What might this individual’s current health status mean for the participant’s future health? Discuss some potential areas for health promotion or prevention of future illness for this individual. (1 paragraph)

5. Planning for future wellness

Discuss 1 health goal you would like to set for this individual, based on the evaluation of the family genetic history and health history, which will promote an optimal level of wellness both now and in the future. Use evidence from the data collected to describe why you feel this goal is a priority, and discuss 2-3 recommended interventions for this individual, based on the goal. (1-2 paragraphs)

Family Genetic & Health History 1

 

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