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:
Your Instructor’s Name:
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.
Disclaimer:When taking a family genetic history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do NOT need to disclose information that they wish to keep confidential. If the adult participant decides not to share information, please write, “Does not want to disclose.” If you find that the client is unwilling to answer several questions, you will need to find another client who can provide more information.
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.
Type your answers on this form. Click Save as and save the file with the assignment name and your last name, e.g., “NR305_Family_Genetic_History_Form_Smith”.When you are finished, submit theform to theFamily 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.
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 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.
| Family Member | Description |
| Paternal grandfatherFirst and last initials: | RL |
| 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 grandmotherFirst and last initials: | ML |
| Birthdate: | 1932 |
| Death date: | 1998 |
| Occupation: | House wife |
| Education: | Does not want to disclose |
| Primary language: | English |
| Health summary: | Diagnosed with chronic lung disease from smoking cigarettes. Died from heart failure. |
This example points to common problems among this generation on both sides of the family. Consider the implications this would have for the adult participant’shealth if these were that person’s family members.
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.”
*Please note any areas left blank will be considered missing information and will result in loss of points*
| Family Member | Description |
| Paternal grandfatherFirst and last initials: | |
| Birthdate: | |
| Death date: | |
| Occupation: | |
| Education: | |
| Primary language: | |
| Health summary: | |
| Paternal grandmotherFirst and last initials: | |
| Birthdate: | |
| Death date: | |
| Occupation: | |
| Education: | |
| Primary language: | |
| Health summary: | |
| FatherFirst and last initials: | |
| Birthdate: | |
| Death date: | |
| Occupation: | |
| Education: | |
| Primary language: | |
| Health summary: | |
| Father’s siblings (write a brief summary of any significant health issues) | |
| Maternal grandfatherFirst and last initials: | |
| Birthdate: | |
| Death date: | |
| Occupation: | |
| Education: | |
| Primary language: | |
| Health summary: | |
| Maternal grandmotherFirst and last initials: | |
| Birthdate: | |
| Death date: | |
| Occupation: | |
| Education: | |
| Primary language: | |
| Health summary: | |
| MotherFirst and last initials: | |
| Birthdate: | |
| Death date: | |
| Occupation: | |
| Education: | |
| Primary language: | |
| Health summary: | |
| Mother’s siblings (write a brief summary of any significant health issues) | |
| Adult ParticipantFirst and last initials: | |
| Birthdate: | |
| Death date: | |
| Occupation: | |
| Education: | |
| Primary language: | |
| Health summary: | |
| Adult participant’s siblings (write a brief summary of any significant health issues) | |
| Adult participant’s spouse/significant otherFirst and last initials: | |
| Birthdate: | |
| Death date: | |
| Occupation: | |
| Education: | |
| Primary language: | |
| Health summary: | |
| 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. Evaluation of family genetic history (30 points)
Evaluate the impact of thefamily’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?
3. Planning for future wellness (45 points)
Plan changes based on the evaluation of the adult participant’sfamily’s health history that will promote an optimal level of wellness both now and in the future. Include what information you would provide to the adult participant regarding the results of the family
