Chamberlain College of Nursing NR305 Health Assessment
Family Genetic History Form
NOTE: Please do NOT remove any of the text on this form. Fill it in and submit in its entirety to aid in its
grading. Failing to complete this assignment using an adult participant other than yourself will result in a
20% penalty deduction being applied. Thank you.
Your Name: Date: 10/31/2017
Your Instructor’s Name: Professor Brenda Trigg
Purpose: This assignment is to help you gain insight regarding the influence of genetics on an individual’s
health and risk for disease. You are to obtain a family genetic history on a willing, nonrelated, adult
participant.
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er as
Disclaimer: When taking a family genetic history on an actual client, it is essential that the information is
co
accurate. Please inform the person you are interviewing that they do NOT need to disclose information
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that they wish to keep confidential. If the adult participant decides not to share information, please
o.
write, “Does not want to disclose.” If you find that the client is unwilling to answer several questions, you
rs e
will need to find another client who can provide more information.
ou urc
Directions: Refer to the Family Genetic History guidelines and grading rubric found in Course Resources
to complete the information below. This assignment is worth 150 points.
o
aC s
Type your answers on this form. Click Save as and save the file with the assignment name and your last
vi y re
name, e.g., “NR305_Family_Genetic_History_Form_Smith”. When you are finished, submit the form to
the Family Genetic History Dropbox by the deadline indicated in your guidelines. Post questions in the Q
& A Forum or contact your instructor if you have questions about this assignment.
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ar stu
1: Family Genetic History (60 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
sh is
children, include them as the fourth generation. **PLEASE NOTE: This assignment is to reveal the
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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.
Family Member Description
Paternal grandfather RL
First and last
initials:
NR305_Family_Genetic_History_Form Rev. 2/8/17 als 1
https://www.coursehero.com/file/26260830/NR305-Family-Genetic-Historydocx/
, Chamberlain College of Nursing NR305 Health Assessment
Birthdate: 1921
Death date: 1981
Occupation: Retired as a coal miner
Education: 6th grade
Primary language: English
Health summary: He was diagnosed with chronic lung disease, diabetes, and hypertension.
He died from a heart attack
Paternal ML
grandmother
First and last
initials:
Birthdate: 1932
Death date: 1998
Occupation: House wife
Education: Does not want to disclose
Primary language: English
Health summary: Diagnose with chronic lung disease from smoking cigarettes. Died from
m
er as
heart failure
This example points to common problems among this generation on both sides of the family.
co
eH w
Consider the implications this would have for the adult participant’s health if these were that
person’s family members.
o.
rs e
Complete the family genetic history form below. Indicate if any information is N/A (not applicable) or
ou urc
unknown. Indicate any information the person did not want to disclose by noting “Does not want to
disclose.”
o
*Please note any areas left blank will be considered missing information and will result in loss of points*
aC s
vi y re
Family Member Description
Paternal grandfather MB
First and last
initials:
ed d
Birthdate: December 18th 1923
Death date: September 8th 1972
ar stu
Occupation: Bus Driver
Education: 6th grade
Primary language: Spanish
Health summary: Diagnosed with hypertension, alcohol dependence, diabetes type II,
sh is
cardiovascular disease, and ultimately died from leukemia
Th
Paternal grandmother SB
First and last
initials:
Birthdate: July 4th 1919
Death date: May 11th 2001
Occupation: Maid
Education: 9th grade
Primary language: Spanish
Health summary: Diagnosed with arthritis, heart murmur, diabetes type II, and ultimately
died from respiratory failure
Father AB
First and last
initials:
NR305_Family_Genetic_History_Form Rev. 2/8/17 als 2
https://www.coursehero.com/file/26260830/NR305-Family-Genetic-Historydocx/
Family Genetic History Form
NOTE: Please do NOT remove any of the text on this form. Fill it in and submit in its entirety to aid in its
grading. Failing to complete this assignment using an adult participant other than yourself will result in a
20% penalty deduction being applied. Thank you.
Your Name: Date: 10/31/2017
Your Instructor’s Name: Professor Brenda Trigg
Purpose: This assignment is to help you gain insight regarding the influence of genetics on an individual’s
health and risk for disease. You are to obtain a family genetic history on a willing, nonrelated, adult
participant.
m
er as
Disclaimer: When taking a family genetic history on an actual client, it is essential that the information is
co
accurate. Please inform the person you are interviewing that they do NOT need to disclose information
eH w
that they wish to keep confidential. If the adult participant decides not to share information, please
o.
write, “Does not want to disclose.” If you find that the client is unwilling to answer several questions, you
rs e
will need to find another client who can provide more information.
ou urc
Directions: Refer to the Family Genetic History guidelines and grading rubric found in Course Resources
to complete the information below. This assignment is worth 150 points.
o
aC s
Type your answers on this form. Click Save as and save the file with the assignment name and your last
vi y re
name, e.g., “NR305_Family_Genetic_History_Form_Smith”. When you are finished, submit the form to
the Family Genetic History Dropbox by the deadline indicated in your guidelines. Post questions in the Q
& A Forum or contact your instructor if you have questions about this assignment.
ed d
ar stu
1: Family Genetic History (60 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
sh is
children, include them as the fourth generation. **PLEASE NOTE: This assignment is to reveal the
Th
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.
Family Member Description
Paternal grandfather RL
First and last
initials:
NR305_Family_Genetic_History_Form Rev. 2/8/17 als 1
https://www.coursehero.com/file/26260830/NR305-Family-Genetic-Historydocx/
, Chamberlain College of Nursing NR305 Health Assessment
Birthdate: 1921
Death date: 1981
Occupation: Retired as a coal miner
Education: 6th grade
Primary language: English
Health summary: He was diagnosed with chronic lung disease, diabetes, and hypertension.
He died from a heart attack
Paternal ML
grandmother
First and last
initials:
Birthdate: 1932
Death date: 1998
Occupation: House wife
Education: Does not want to disclose
Primary language: English
Health summary: Diagnose with chronic lung disease from smoking cigarettes. Died from
m
er as
heart failure
This example points to common problems among this generation on both sides of the family.
co
eH w
Consider the implications this would have for the adult participant’s health if these were that
person’s family members.
o.
rs e
Complete the family genetic history form below. Indicate if any information is N/A (not applicable) or
ou urc
unknown. Indicate any information the person did not want to disclose by noting “Does not want to
disclose.”
o
*Please note any areas left blank will be considered missing information and will result in loss of points*
aC s
vi y re
Family Member Description
Paternal grandfather MB
First and last
initials:
ed d
Birthdate: December 18th 1923
Death date: September 8th 1972
ar stu
Occupation: Bus Driver
Education: 6th grade
Primary language: Spanish
Health summary: Diagnosed with hypertension, alcohol dependence, diabetes type II,
sh is
cardiovascular disease, and ultimately died from leukemia
Th
Paternal grandmother SB
First and last
initials:
Birthdate: July 4th 1919
Death date: May 11th 2001
Occupation: Maid
Education: 9th grade
Primary language: Spanish
Health summary: Diagnosed with arthritis, heart murmur, diabetes type II, and ultimately
died from respiratory failure
Father AB
First and last
initials:
NR305_Family_Genetic_History_Form Rev. 2/8/17 als 2
https://www.coursehero.com/file/26260830/NR305-Family-Genetic-Historydocx/
