Family Interview Assessment

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Values and Health Perception

1.What is your perceived ability to control your health?

2. What is some self-care measures used?

Nutrition

1.How many servings of fruits and vegetables do you eat daily?

2.What is your idea of healthy eating?

3.What has your diet consisted of over the last 24 hours?

Sleep/Rest

1.What is your normal sleep schedule (Time you go to bed, and time you wake up?)

2.Do you have any uncommon sleep patterns or difficulty sleeping?

Elimination

1.What are the usual elimination patterns for the family?

2.Are there any difficulty, discomfort, or assistance (such as catheters, colostomies, diapers, etc.) needed?

Activity/Exercise

1.How often do you exercise or have some kind of activity and for how long every week?

2.What is your occupation and how much activity does it require?

3.What is your ability to carry out activities of daily living?

Cognitive

1.What are the levels of education in the family?

2.What are the mental statuses of the family members and the ability to understand?

3.How is the communication in the family and between the family members?

Sensory-Perception

1.Are there any vision or hearing difficulties present?

2.Is there any pain issues?

Self-Perception

1.Are there any illness contributing to self perception?

2.What are the family’s emotional status, body image, and feelings about self?

Role Relationships

1.What are the family member’s relationships, significant others, and next of kins?

2.What role does everyone in the family fill?

3.What available assistance is there in the case of health challenges?

Sexuality

1.Are there any sexual activity concerns regarding contraception and pregnancy?

2.Are there any menstrual cycle concerns or obstetrical history?

Coping

1.What are your coping strategies and their effectiveness?

2.Have there been any personal losses or major stresses...
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