Chamberlain

College of Nursing NR305

Family Genetic & Health History Rev. 6/2019KC 1

Family Genetic & Health History Assignment

Your Name:

Date:

Your Instructor’s Name:

Directions: Refer to the Family Genetic and Health History guidelines and grading rubric included in your

assignment email to complete the information below. This assignment is worth 200 points.

1: Family Genetic History (50 points):

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 assignment 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 no t want to disclose by noting “Does not want to

disclose.”

*Please note any areas left blank will be considered missing information and will result in loss of points*

Family Member Description

Paternal grandf ather

First and last

initials:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Chamberlain College of Nursing NR305

Family Genetic & Health History Rev. 6/2019KC 2

Health summary

(include cause of

death if applicable):

Paternal

grandm

other

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

signif icant health

issues)

Maternal grandf ather

First and last
initials:

Chamberlain College of Nursing NR305

Family Genetic & Health History Rev. 6/2019KC 3

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):

Chamberlain College of Nursing NR305

Family Genetic & Health History Rev. 6/2019KC 4

Mother’s siblings

(write a brief
summary of any
signif icant 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
signif icant health
issues)

Adult participant’s

spouse/signif icant

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 f or each

Chamberlain College of Nursing NR305

Family Genetic & Health History Rev. 6/2019KC 5

child, up to f our

children)

Child #1 f irst and last

initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:

Child #2 f irst and last

initials:

Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:

Child #3 f irst and last

initials:

Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:

Child #4 f irst and last

initials:

Birthdate:

Chamberlain College of Nursing NR305

Family Genetic & Health History Rev. 6/2019KC 6

Death date:
Occupation:
Education:
Primary language:
Health summary:

2. Health History (75 pts)

BIOGRAPHICAL DATA (5 points)

Date:

Initials:

Age:

Date of birth:

Birthplace:

Gender:

Marital status:

Race:

Occupation:

Source of information:

Reliability of source of information:

PRESENT HEALTH HISTORY/ILLNESS

(5

points)

Health goals:

MEDICATIONS (10 points)

Include purpose, dose, duration,

frequency, and any desired or

undesired effects for each

medication.

Chamberlain College of Nursing NR305

Family Genetic & Health History Rev. 6/2019KC 7

Prescription medications:

Over-the-counter medications:

Herbals:

PAST HISTORY (5 points)

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 (5 points)

Mental, emotional or psychiatric

problems:

PSYCHOSOCIAL/ OCCUPATIONAL

HISTORY (5 points)

Occupational history:

Educational level:

Financial background:

ROLES AND RELATIONSHIPS (5)

points)

Chamberlain College of Nursing NR305

Family Genetic & Health History Rev. 6/2019KC 8

Significant others:

Support systems:

ETHNICITY AND CULTURE (5 points)

Ethnicity and culture:

Physical and social characteristics

that influence healthcare decisions:

SPIRITUALITY (5 points)

Beliefs and practices influencing

health decisions:

Religious and spiritual needs:

REVIEW OF SYSTEMS (25 points)

(This is not a physical examination.

Refer to Ch. 6 of your textbook as

needed.)

Skin, hair, nails:

Head, neck, related lymphatics:

Eyes:

Ears, nose, mouth, and throat:

Respiratory:

Breasts and axillae:

Cardiovascular:

Peripheral vascular:

Abdomen:

Urinary:

Reproductive:

Musculoskeletal:

Chamberlain College of Nursing NR305

Family Genetic & Health History Rev. 6/2019KC 9

Neurologic:

3. Evaluation of family genetic history (25 points)

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 (25 points)

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 (25 points)

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, b ased on the goal. (1-2 paragraphs)