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What is your family ancestry? What is the profile of your family? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ This should include grandfather, grandmother, father, mother, brothers, sisters, cousins, other relatives, spouse, and children, if any. If you have any difficulty in describing your family, here are various guidelines. What best describes your family? I do not know anything about my family. I was brought up by foster parents. I was an abandoned child. I became a victim of a criminal conspiracy while I was a child.(What are the details?) I have a court endorsed guardian. I have a brief description of my family. (What are the details of my family?) My parents are not alive. My parents are alive and I communicate with them regularly. What state, region, and continent did your mother and father come from? __________________________________________________________________ North American States Asian States Africa Australia Latin What was the religion of your mother and father? __________________________________________________________________ Who are your family members as of February 15, 2012? __________________________________________________________________ Who were your family members at the time of your birth? __________________________________________________________________ List profile of mother, father, brothers, sisters, grandparents, and extended family members. Do you have any brothers and sisters? __________________________________________________________________ How many brothers and sisters do you have? __________________________________________________________________ Where are they located? __________________________________________________________________ Please list any family members who have died from serious diseases. __________________________________________________________________ What diseases did your deceased relatives have? __________________________________________________________________ Disease: Relation: Age: Do you have a family history of any of the following? Uterine Cancer Yes No Family Member (s) Ovarian Cancer Yes No Family Member (s) Fibrocystic Breast Yes No Family Member (s) Breast Cancer Yes No Family Member (s) Heart Disease Yes No Family Member (s) Osteoporosis Yes No Family Member (s) Prematurely gray Yes No Family Member (s) __________________________________________________________________ __________________________________________________________________ Please list family members - and their age - who have had serious diseases such as diabetes, heart disease, cancer, osteoporosis, etc. __________________________________________________________________ Disease: Relation: Age: How old were they when they died? __________________________________________________________________ What caused their deaths? __________________________________________________________________ Family Health History Q: What is family history? A: Family history refers to health information about you and your close relatives. Why is asking about family essential? These examples will make you understand. On October 23, 2012, Yingjia Wang (Bonny) has been in Chicago, Illinois, for the past month. She is 22 years old, and originally from Bejing. She does not have family in Chicago, Illinois. She needs extra care. Who has the duty to take care of her in Chicago, Illinois? On October 23, 2012, Laura Eberly has been in Chicago, Illinois, for the past few years. She is 22 years old. I/we do not know about her family. She has been given a work description that does not meet the standard description of any profession/work/job. Take a look at this. http://www.qureshiuniversity.com/professionsworld.html Is someone behind the scenes misleading her? If her family is not in Chicago, Illinois, who should supervise her? What profession/work/job description do your activities fit into? Public relations officer Public relations supervisor. Female _________________________________________________________________ What is the ethnicity of the female? _________________________________________________________________ Where is the spouse of the female and what are his name, age, and profile? _________________________________________________________________ Are there any controversies, disputes, or claims? Is this pregnancy from her genuine spouse without any controversies, conspiracies, disputes, or claims? _________________________________________________________________ Where are the patient's parents and other family members? _________________________________________________________________ Where and when did the patient have prenatal or pre-pregnancy medical consultations? _________________________________________________________________ What is the profile, mailing address, contact information of such people or establishment? _________________________________________________________________ Is it a medico legal case? _________________________________________________________________ Where should you report about a medico legal case? _________________________________________________________________ Is medical termination of pregnancy applicable to this scenario? _________________________________________________________________ Does this need emergency contraception or medical termination of pregnancy? _________________________________________________________________ Who will do the procedure, if required? _________________________________________________________________ If there are any controversies, medico legal issues, conspiracies, disputes, or claims, fix them first and then go ahead with the pregnancy. Family planning What does family planning include? 1. Relationship counseling 2. Legitimate spouse 3. Legitimate conception 4. Prenatal counseling 5. Delivery 6. Post-delivery counseling 7. Raising the child. A person asks for babysitter. Should you ask for a babysitter? _________________________________________________________________ No, you should not. _________________________________________________________________ Who has responsibility to raise the child? _________________________________________________________________ It is the responsibility of the parents to raise the child. _________________________________________________________________ What if the child is born due to a conspiracy? _________________________________________________________________ All those involved have to be punished. _________________________________________________________________ Do the family members have required social skills? _________________________________________________________________ Who are his or her family members? _________________________________________________________________ Who are his or her community members? _________________________________________________________________ Do the community members have required social skills? _________________________________________________________________ What skills and knowledge will you teach that I do not know? _________________________________________________________________ How did you review my family? _________________________________________________________________ How do you define a family? _________________________________________________________________ Who do you include and not include in my family? _________________________________________________________________ How did you verify and review the composition of my family? _________________________________________________________________ Language What languages do you understand? _________________________________________________________________ Do you understand the English language? _________________________________________________________________ What language do you speak with your family members? _________________________________________________________________ What language do you speak normally in the community? _________________________________________________________________ What language news do you read and listen to? _________________________________________________________________ What various languages are you able to understand, write, read, and speak? _________________________________________________________________ Birth Do you have proper family planning guidelines for you before the birth? _________________________________________________________________ What and where can one get proper family planning guidelines for the birth and after the birth? _________________________________________________________________ Do you have a name ready for the child? _________________________________________________________________ Do you live with a family? _________________________________________________________________ Do you have a family? _________________________________________________________________ Who are your immediate family members? _________________________________________________________________ What are their assets? _________________________________________________________________ How do you define a family? _________________________________________________________________ How is this affecting the other members of the family? _________________________________________________________________ How are your children getting on at school? _________________________________________________________________ How does your spouse respond to your problems? _________________________________________________________________ How are you getting on with him/her? _________________________________________________________________ Can I speak to him/her about it? _________________________________________________________________ Have you ever felt this way before? _________________________________________________________________ What did you do about it? _________________________________________________________________ What really helped? _________________________________________________________________ What is the source of your (food,etc)? _________________________________________________________________ Do you have enough food, clothes, housing, transportation, health care, and resources? _________________________________________________________________ What is good human behavior in the family? _________________________________________________________________ Are you living alone or in a joint family? _________________________________________________________________ Do you prefer to live alone or in a joint family? _________________________________________________________________ Was there any incident in the area or elsewhere that was not reported but should have been reported? _________________________________________________________________ What are the details of the incident? _________________________________________________________________ Do you have enough food, clothing, transportation, health care, industry- specific, situation-specific education, security, housing, or building needs, maintenance services, consumer goods, or communications? __________________________________________________________________ What would you like to have enhanced? __________________________________________________________________ How would you like to elaborate on these facts? |