Family Interview

Part 1 — Family Identification & Basic Information

Family ID / Initials

O.S

A.S

C.S

Interview Date

09/05/2026

Interviewer Initials

G.G

City / Neighborhood

Miami Shores

Housing Type

Single family home

Primary Language

Creole

Family Type

Nuclear

Number of Household Members

4

Part 2 — Family Member Roster

Initials

Age

Sex

Relationship to Head

Occupation / School

Known Health Conditions

C.S

33

F

Head of household

Registered Nurse

Hypertension

O.S

77

M

Father

Retired

Cardiomyopathy, Stage 3 kidney disease and Hypertension

A.S

64

F

Mother

Cook

hypertension, and Type II Diabetes

Part 3 — Family Structure & Function

Primary Decision-Maker

C.S

Primary Communication Style

Supportive and collaborative

☐ Family discussion

☐ Prayer/religion

☐ Social support

☐ Professional help

☐ Exercise/activity

☐ Avoidance/denial

☐ Substance use

☐ Financial planning

☐ Humor/levity

☐ Other: ___________

Describe family roles (caregiver, breadwinner, etc.) and any role strain or conflict

C.S is the breadwinner & caregiver A.S is the homemaker and cook

Family Cohesion

Circle one: 1 — Very disconnected 2 3 — Moderate 4 5 — Very close

Part 4 — Health History & Patterns

☐ Hypertension

☐ Type 2 diabetes

☐ Heart disease

☐ Asthma / COPD

☐ Obesity

☐ Cancer (any)

☐ Mental health disorder

☐ Substance use disorder

☐ Stroke

☐ Arthritis

☐ Kidney disease

☐ Hypercholesterolemia

☐ Other: ___________

Recent Significant Health Events (last 12 months)

O.S elevated blood pressure and difficulty breathing due to fluid retention.

Family Health History / Genetic Risk (link to genogram)

Grandparents died of stroke

Annual physicals / well-visits

Vaccinations up to date

Dental care in the past year

Vision care in the past year

√☐ Yes ☐ No

☐ Some members

☐ Yes ☐ No

☐ Some members

☐ Yes ☐ No

☐ Some members

☐ Yes ☐ No

☐ Some members

Typical Diet Quality

Physical Activity Level

Tobacco Use in the Household

Alcohol / Substance Use Concerns

☐ Mostly balanced

☐ Mixed

☐ Mostly processed

☐ Food insecure

☐ Regular (≥3×/week)

☐ Occasional

☐ Rarely or never

☐ None

☐ 1 member

☐ 2+ members

☐ Former user(s)

☐ None reported

☐ Possible concern

☐ Confirmed concern

☐ In treatment

Part 5 — Social Determinants of Health (SDOH)

Estimated Household Income

Health Insurance Status

Highest Education Level

Employment Status

☐ Below poverty (<$15k)

☐ Low ($15k–$30k)

☐ Lower-middle ($30k–$55k)

☐ Middle ($55k–$100k)

☐ Above middle (>$100k)

☐ Prefer not to say

☐ All members insured

☐ Some uninsured

☐ All uninsured

☐ Medicaid / CHIP

☐ Medicare

☐ Less than high school

☐ High school / GED

☐ Some college

☐ Associate’s degree

☐ Bachelor’s degree

☐ Graduate degree

☐ All adults full-time

☐ Mixed (part-time)

☐ Unemployed

☐ Retired / disability

☐ No insurance

☐ Cost/copays

☐ Transportation

☐ Language barrier

☐ No regular provider

☐ Long wait times

☐ Work schedule conflicts

☐ Distrust of the system

☐ Childcare constraints

☐ No perceived need

☐ Other: ___________

Neighborhood Safety Perception

Safe for everyone crosse walks on every street/

Transportation Access

Public and private transportation

Social Support Network (describe connections — also reference ecomap) Church weekly attendance,

Other SDOH Concerns (food security, access to technology, domestic safety, immigration status, etc.)

Part 6 — Primary Need)s)/Levels of Prevention

Priority Health Need(s) Identified good daily dieting to maintain blood pressure, medication compliance, daily exercise.

Level of Prevention

Check one:

☐ Primary — prevent the onset of disease/problem before it occurs

☐ Secondary — early detection/screening/ early treatment

☐ Tertiary — manage existing condition/rehabilitation