Assign to Doc Daimler

Health History Worksheet This worksheet is used to assist the student in gathering and organizing information when conducting a health history.

Family Member Description Paternal grandfather

First and last initials: L. M. Birthdate: April 11 1916 Death date: April 1984 Occupation: Private business man Education: some college Primary language: English Health summary: passed from lymphoma and lung cancer

Paternal grandmother First and last initials: C. M. Birthdate: May 20 1919 Death date: December 1980 Occupation: House wife Education: high school Primary language: English Health summary: passed from aneurism

Father First and last initials: W. M. Birthdate: October 25 1959 Death date: Alive Occupation: Failure Analysis Engineer at NASA Education: Bachelors from Mississippi State Primary language: English Health summary: Severe neck Arthritis

Father’s siblings- Summary of any significant health issues

One sibling with cancer, one sibling with fibromyalgia

Maternal grandfather First and last initials: Unknown Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Maternal grandmother First and last initials: E. V. Birthdate: June 1940 Death date: August 1978 Occupation: House wife Education: none Primary language: Spanish Health summary: passed from Stomach cancer

Mother First and last initials: R. V. M. Birthdate: July 1 1961 Death date: Alive Occupation: house wife Education: Some high school Primary language: Spanish Health summary: No health conditions

Mother’s siblings- Summary of any significant health issues No health conditions Adult Participant

First and last initials: B.M. Birthdate: July 27 1998 Death date: Alive Occupation: Student Education: College Primary language: English Health summary: No serious health conditions

Adult participant’s siblings Summary of any significant health issues None Adult participant’s spouse/significant other

First and last initials: N/A Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Adult participant’s children- Up to 4 children N/A 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:

Family Member Description Paternal grandfather

First and last initials: L. M. Birthdate: April 11 1916 Death date: April 1984 Occupation: Private business man Education: some college Primary language: English Health summary: passed from lymphoma and lung cancer

Paternal grandmother First and last initials: C. M. Birthdate: May 20 1919 Death date: December 1980 Occupation: House wife Education: high school Primary language: English Health summary: passed from aneurism

Father First and last initials: W. M. Birthdate: October 25 1959 Death date: Alive Occupation: Failure Analysis Engineer at NASA Education: Bachelors from Mississippi State Primary language: English Health summary: Severe neck Arthritis

Father’s siblings- Summary of any significant health issues

One sibling with cancer, one sibling with fibromyalgia

Maternal grandfather First and last initials: Unknown Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Maternal grandmother First and last initials: E. V. Birthdate: June 1940 Death date: August 1978 Occupation: House wife Education: none Primary language: Spanish Health summary: passed from Stomach cancer

Mother First and last initials: R. V. M. Birthdate: July 1 1961 Death date: Alive Occupation: house wife Education: Some high school Primary language: Spanish Health summary: No health conditions

Mother’s siblings- Summary of any significant health issues No health conditions Adult Participant

First and last initials: B.M. Birthdate: July 27 1998 Death date: Alive Occupation: Student Education: College Primary language: English Health summary: No serious health conditions

Adult participant’s siblings Summary of any significant health issues None Adult participant’s spouse/significant other

First and last initials: N/A Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Adult participant’s children- Up to 4 children N/A 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:

Family Member Description Paternal grandfather

First and last initials: L. M. Birthdate: April 11 1916 Death date: April 1984 Occupation: Private business man Education: some college Primary language: English Health summary: passed from lymphoma and lung cancer

Paternal grandmother First and last initials: C. M. Birthdate: May 20 1919 Death date: December 1980 Occupation: House wife Education: high school Primary language: English Health summary: passed from aneurism

Father First and last initials: W. M. Birthdate: October 25 1959 Death date: Alive Occupation: Failure Analysis Engineer at NASA Education: Bachelors from Mississippi State Primary language: English Health summary: Severe neck Arthritis

Father’s siblings- Summary of any significant health issues

One sibling with cancer, one sibling with fibromyalgia

Maternal grandfather First and last initials: Unknown Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Maternal grandmother First and last initials: E. V. Birthdate: June 1940 Death date: August 1978 Occupation: House wife Education: none Primary language: Spanish Health summary: passed from Stomach cancer

Mother First and last initials: R. V. M. Birthdate: July 1 1961 Death date: Alive Occupation: house wife Education: Some high school Primary language: Spanish Health summary: No health conditions

Mother’s siblings- Summary of any significant health issues No health conditions Adult Participant

First and last initials: B.M. Birthdate: July 27 1998 Death date: Alive Occupation: Student Education: College Primary language: English Health summary: No serious health conditions

Adult participant’s siblings Summary of any significant health issues None Adult participant’s spouse/significant other

First and last initials: N/A Birthdate: Death date: Occupation: Education: Primary language: Health summary:

Adult participant’s children- Up to 4 children N/A 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:

An example 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 Adult Participant’s family. Consider the potential implications this would have for the Adult Participant’s health status.