Family Genetic History Form YourName: 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.” Directions: Refer to the Family Genetic History guidelines and grading rubric found in Doc Sharing to complete the information below. This assignment is worth 100 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 (35 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 grandfather First 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 grandmother First 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.” Family Member Description Paternal grandfather First and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary: Paternal grandmother First and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary: Father First 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 grandfather First and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary: Maternal grandmother First and last initials: Birthdate: Death date: Occupation: Education: Primary language: Health summary: Mother First 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 Participant First 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 other First 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 (25 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 (35 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 genetic history.
