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Family Health Assessment

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Nies: Community/Public Health Nursing 6
th
Ed.
Resource Tool 20A: Family Health Assessment Form
Name
Family surname: S
Household members
Family composition:
Family characteristics
Source(s) of
Information
Date
Extended family:
-Relatives living outside household
7
-Location of relatives
KANSAS CITY, MO
OVERLAND
PARK, KS
SHAWNEE,KS
PAOLA,KS
-Frequency and duration of contact
WEEKLY
2+ HOURS
-Means of communication
FACE TO FACE
PHONE
Family mobility:
-Length of time living in residence
6 YEARS
-Frequency of geographic moves
NEVER
-Country/area of origin
USA
Family structure:
-Educational experiences
HIGH SCHOOL
DIPLOMA
-Employment history
FULLTIME JOB
WITH SAME
COMPANY
STARTED WITH
AT 16
-Financial resources
FULLTIME JOB
-Leisure time interests
MOTORCYCLE
RIDING
-Division of labor
SINGLE DOES
ALL LABOR
-Allocation of roles
HEAD OF
HOURSEHOLD
-Distribution of authority and power
SINGLE MAN
MAKES ALL
DECISIONS
Family cohesion:
-Emotional bonding of family members
VERY CLOSE
SEES EACH
OTHER EVERY
WEEK FOR
DINNER
-Degree of individual autonomy
LISTENS AND
HEEDS ADVICE
OF PARENTS
Family adaptation:
-Flexibility in role change
FLEXIBLE

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Nies: Community/Public Health Nursing 6
th
Ed.
Resource Tool 20A: Family Health Assessment Form
Name
-Flexibility in power structures
FATHER HOLD
POWER
Family processes:
-How members communicate
PHONE
FACE TO FACE
CONVERSATIONS
-How decisions are made
WITH ADVICE
FROM FATHER
AND MOTHER
-How problems are solved
DISCUSSION AND
COMPROMISE
-How conflict is handled
COMMUNICATION
Family social integration:
-Language(s) and/or dialect(s) spoken: where
ENGLISH
-Literacy/ ability to read or write in language(s)
ENGLISH
-Degree of racial or cultural identity
WHITE
-Degree of social network with neighbors, friends, & other family members
VERY SOCAIL
-Network with religious organizations
CHRISTIAN
-Network with social organizations
MANY FRIENDS
WITH MONTHLY
SOCAIL
GATHERINGS
Degrees of stress experienced by the family
-Combinations of stressors:
1. MONEY
2. WORK
3.RELATIONSHIPS
Family health behavior:
-Activities of daily living (how family spends typical day)
GOES TO WORK,
GOES TO GYM,
PICKS UP
DINNER,
WATCHES TV
GOES TO BED.
-Health history
GOOD GENERAL
HEALTH
-Health status (i.e., problems and priorities)
NONE
-Risk behaviors
DRINKS
ALCOHOL, RIDES
MOTORCYCLES
-Self-care (health promotion and prevention)
WORKSOUT IN
THE GYM
-Health care resources
-Professionals and lay healers
PRIMARY CARE
PHYSICIAN
-Working with family and agencies
NONE

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Nies: Community/Public Health Nursing 6th Ed. Resource Tool 20A: Family Health Assessment Form Name Family surname: S Household members Family composition: Family characteristics Extended family: -Relatives living outside household -Location of relatives -Frequency and duration of contact -Means of communication Source(s) of Information 7 KANSAS CITY, MO OVERLAND PARK, KS SHAWNEE,KS PAOLA,KS WEEKLY 2+ HOURS FACE TO FACE PHONE Family mobility: -Length of time living in residence 6 YEARS -Frequency of geographic moves NEVER -Country/area of origin USA Family structure: -Educational experiences -Employment history -Financial resources -Leisure time interests -Division of labor -Allocation of roles -Distribution of authority and power Family cohesion: -Emotional bonding of family members -Degree of individual autonomy Family adaptation: -Flexibility in role change HIGH SCHOOL DIPLOMA FULLTIME JOB WITH SAME COMPANY STARTED WITH AT 16 FULLTIME JOB MOTORCYCLE RIDING SINGLE DOES ALL LABOR HEAD OF HOURSEHOLD SINGLE MAN MAKES ALL DECISIONS VERY CLOSE SEES EACH OTHER EVERY WEEK FOR DINNER LISTENS AND HEEDS ADVICE OF PARENTS FLEXIBLE Date Nies: Community/Public Health Nursing ...
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