Family Assessment Form

Selection of a Patient Family Important criteria for selecting a family include: Availability of the patient along with other family members for an interview and the patient and familys ability to provide family information. The family should consist of two or more persons. The family member or index patient interviewed should have a health related issue, which has or will have an impact upon the entire family. Examples of such health related experiences include accidental injury, surgery, stroke, depression and chronic illnesses such as diabetes, hypertension, cardiovascular disease or others as deemed appropriate following preceptor and student discussion. The student, if preferred, can make a home visit to this patient and his/her family. Use the following pages as a guideline for data collection. Be prepared to return this form on the final day of the clerkship. The student will be asked to make a short presentation of 10 minutes or less in a small group setting and discuss the family assessment. Copies of the genogram will be made for you to distribute to group members. Information herein was obtained through: (check one or more) _____ Medical Record Review _____ Discussion with my Preceptor _____ Interview in Office _____ Home Visit _____ Interview in Hospital

Section I:
A.

Brief History and Pertinent Biomedical Findings

General Information Sex: _______Male _______Female Age:_______

Occupation:_______________________ Level of Education:_________________

Diagnosis(es):

When Diagnosed:

Pertinent biomedical information:

B.

Impact of Illness Are there any limitations in physical activity as a result of illness?

Are there any changes in family patterns (interaction patterns, working patterns, child care patterns)?

Has the illness affect(ed) the entire family? If yes, how?

How does the patient spend free time?

Section II: Family Assessment

Genogram A. Include at least three generations of biomedical and psychosocial information and include critical events.

Family Apgar B. Have the patient complete the family apgar. Any other family members may complete one as well. Indicate the familys apgar numerically. Column one is 2 points almost always, column two is 1 point some of the time and column three is 0 points hardly ever.

Genogram

FAMILY APGAR After you have completed the majority of the interview, ask the patient to complete the following brief questionnaire. Ask him/her to put one check in the appropriate column for each question. Comments are optional. Almost Some Of Hardly Always The Time Ever I am satisfied that I can turn to my family for help when something is troubling me. Comments:

______

______

______

I am satisfied with the way my family talks over things with me and shares problems with me. Comments:

______

______

______

I am satisfied that my family accepts and supports my wishes to take on new activities or directions. Comments:

______

______

______

I am satisfied with the way my family expresses affection and responds to my emotions, such as anger, sorrow or love. ______ Comments:

______

______

I am satisfied with the way my family and I share time together. Comments:

______

______

______

Family is defined in this questionnaire as the individual(s) with whom you usually live. If you live alone, consider family as those with whom you now have the strongest emotional ties.

Section II

Your Conclusions

Review the genogram and the family apgar. List the critical events in the life of this family. Typically these nodal events are such things as a major illness or accident, divorce or other loss. Did the critical events result in significant change in family interaction patterns?

Which family interaction patterns appear satisfactory and effective to the members involved?

Which family interaction patterns appear unsatisfactory and ineffective to the members involved?

What stage of the family life cycle is this family in? (a discussion is in your packet)

On a scale of 0-10, how would you rate this familys level of function? Use the Family Apgar to discuss why.

If you were managing this patient/family, what would be your management plan? Discuss any preventive medicine issues.

Discuss the impact this family assessment had/has upon your patient management plan.