This document contains a personal background form requesting information about an individual including their name, age, address, relationship status, living situation, cultural background, employment, education, family, and medical history. It collects details on their ethnicity, languages spoken, cultural practices, family structure, current and past health issues, medication usage, and alcohol consumption through a series of yes or no and short answer questions.
This document contains a personal background form requesting information about an individual including their name, age, address, relationship status, living situation, cultural background, employment, education, family, and medical history. It collects details on their ethnicity, languages spoken, cultural practices, family structure, current and past health issues, medication usage, and alcohol consumption through a series of yes or no and short answer questions.
This document contains a personal background form requesting information about an individual including their name, age, address, relationship status, living situation, cultural background, employment, education, family, and medical history. It collects details on their ethnicity, languages spoken, cultural practices, family structure, current and past health issues, medication usage, and alcohol consumption through a series of yes or no and short answer questions.
This document contains a personal background form requesting information about an individual including their name, age, address, relationship status, living situation, cultural background, employment, education, family, and medical history. It collects details on their ethnicity, languages spoken, cultural practices, family structure, current and past health issues, medication usage, and alcohol consumption through a series of yes or no and short answer questions.
3. Please describe your ethnic/racial identity in your own words.
4. What language do you use in your tribe? Primary and Secondary languages.
5. What are your common hygiene practices learned from your tribe?
6. What are your clothings or ornamentation?
7. What are your religious practices among your tribe? 8. Do you have any rituals of death and birth? If yes, please describe. 9. In your tribe, what are your beliefs in the gender roles of your family in your household? 10. What are your food habits and dietary restriction? 11. What are your medical practices in your tribe? 12. When sick, what kind of treatment do you use? Include any medicinal herbs if there’s any. 13. What are your food refusals in your culture, religion? 14. What are common resources in your community? How are they managed? 15. What is a proverb in your language that most appeals to you? Why? 16. What, if anything, do you see when you visualize yourself 10 years from now? EMPLOYMENT 17. Are you currently employed? Yes, full-time Yes, part-time No, currently unemployed If yes, what type of work do you do? 18. Please indicate the number of adults & children living in your household: adults children
19. How satisfied are you with your currently financial situation? Not Satisfied at all Somewhat Satisfied Very Satisfied
EDUCATION 20. How many years of schooling have you completed?
21. Are you currently in school?
Yes No If yes, what are you studying?
FAMILY INFORMATION
22. Please provide the following information about your family:
Mother Full Name: If deceased, year and cause of death: If living, age and health status: If living, where does she live now? Her occupation (past and/or present) Father Full Name: If deceased, year and cause of death: If living, age and health status: If living, where does he live now? His occupation (past and/or present) Other guardians/parental figures (e.g., step-parent, partner of parent, aunt): Full Name(s): If deceased, year and cause of death: If living, age and health status: If living, where does (s)he live now? His/her occupation (past and/or present)
Siblings:
Name Age Occupation Where located?
MEDICAL HISTORY 23. Have you had a physical examination within the last six months? Yes No If yes, what were the results:
24. Are you currently receiving medical care? Yes No
If yes, please describe briefly:
25. Have you experienced any of the following health problems? Please check all that apply: High blood pressure/Hypertension Ulcer or gastrointestinal problem Cardiac/Heart problems Kidney disorder Cancer Chronic or frequent headaches Diabetes Dizziness Respiratory problems Fainting or Blackouts Chronic pain Injury: What kind? Stroke Seizures/Convulsions Headaches Memory problems Thyroid Issues Asthma Any other health problems?
26. Have you been hospitalized for illness or injury in the past 10 years? Yes No If yes, approximate dates and condition:
27. Are you currently taking any medications? Yes No
Type of Medication Average Dosage Frequency
28. Have there been any serious illnesses, accidents, deaths or other physical concerns within your family in the past 5 years? Yes No If yes, please specify:
29. Do you drink alcohol? Yes No
If yes, how much do you drink? drinks per day If yes, do you feel your drinking has caused any problems in your work, school, or relationships? Yes No Please explain:
The Everything Guide to Thyroid Disease: From potential causes to treatment options, all you need to know to manage your condition and improve your life
The Everything Guide to Thyroid Disease: From potential causes to treatment options, all you need to know to manage your condition and improve your life
