Questionnaire on Family Health Assessment

Assessment Description Understanding family structure and style is essential to patient and family care.

Conducting a family interview and needs assessment gathers information to identify strengths, as well as potential barriers to health. This information ultimately helps develop family-centered strategies for support and guidance. This family health assessment is a two-part assignment. The information you gather in this initial assignment will be utilized for the second assignment in Topic 3. Develop an interview questionnaire to be used in a family-focused functional assessment. The questionnaire must include three open-ended, family-focused questions to assess functional health patterns for each of the following: Values/Health Perception Nutrition Sleep/Rest Elimination Activity/Exercise Cognitive Sensory-Perception Self-Perception Role Relationship Sexuality Coping Select a family, other than your own, and seek permission from the family to conduct an interview. Utilize the interview questions complied in your interview questionnaire to conduct a family-focused functional assessment. Document the responses as you conduct the interview.

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Questionnaire on Family Health Assessment

Value/Health Perception

  • What reflects the family values for your children’s health?

The main family values that impact our children’s health is having a supportive family and a close-knit which gives them economic well-being and emotional support, thus impacting their overall health.

  • Do you follow the physician’s recommendation every time?

We always ensure that we do to better our overall health outcomes.

  • Why is health the most significant priority in your family?

We always ensure that we make health our priority since we understand that bad health can affect every member’s emotional, physical and economic well-being.


  • How many times do you consume nutritious foods?

As a family, we always try to uphold a balanced diet daily with minimal snacks.

  • Do you check on the nutritional value labels when buying foods?

As a matter of fact, we rarely check on nutritional value labels since we know the food we require to eat daily because they already have the recommended nutritional value.

  • Which unhealthy foods do your children consume most?

Our children are used to frozen French fries and ice cream when we take them though we always try to control their consumption.

Sleep and Rest

  • How many hours do you sleep daily and why?

In our home, we have a different sleeping schedule. For instance, our children sleep for eight hours to ten, depending on the school homework workload. On the other hand, we as parents have the poorest sleep schedule since I always sleep for four hours on average due to my work schedule the same with the children’s mother since she can even stay awake overnight watching her favorite soaps.

  • Do any of your family members snore?

We are lucky that none of our family members snores.

  • How do you realize that you have had enough sleep?

For the children, we always realize that they have had enough sleep during the weekend since they wake themselves up. However, for my wife and I, we only have enough sleep during holidays, though she always complains that she never has enough sleep during school days or holidays since she has no house manager.


  • Does every family member have regular bowel movements?

Yes. We have no complaints so far.

  • How many times does each of you visit the washroom?

It is hard to tell since we are all away from each other most times.

  • Do you see any benefits of elimination in your family?

Yes. Because without elimination, we will start speculating that the family member has some issues that require the medic’s attention.


  • What main exercise do you carry out?

We do engage in hiking during holidays only

  • How many times do you exercise, and for how long?

Precisely, we hike five times a year, with these hikes taking a minimum of three hours depending on our chosen location.

  • Do you participate in sports, and why?

No family member participates in a sport resulting from a lack of interest in sports.


  • How do you make your decisions?

We like engaging each family member in our decision-making process except for marital and financial issues for everyone to feel engaged.

  • Does any family member get confused when making decisions?

Yes. The children always seem to find it hard while making their own decisions. So, as their parents, we always help them in case of an obstacle in decision making.

  • What obstacles do you face when learning something new?

Sensory Perception

  • Have you ever engaged in eye check-ups?

No. Since no family member has complained of eye problems

  • Is there any family member with hearing problems?


  • Do you have taste problems?



  • What do you like about yourself as an individual?
  • Eight years old- I know how to draw, which makes most of my classmates praise me.
  • Ten-year-old- I like helping my classmate whenever they have any problem. Where I cannot offer physical help, I always pray for them.
  • The Mother- I like my role as the main chef of my family since I manage to ensure that my family feeds healthy and nutritious food. However, we all love him for my younger baby since he is a quick learner and less stubborn compared to kids of the same age.
  • The father- I like my selfless nature where I overwork to keep my family financially fit.
  • Do you get depressed? If so, how do you deal with the situation?
  • The mother- Yes. I do get depressed but watching TV and participating in community work helps me overcome the extreme signs and symptoms of a depressed person.
  • Father- I am always depressed by the work I do daily, but I overcome it daily by taking a cold shower and sleep as soon as I am done with taking my late supper.
  • Does other people’s opinion affect your self-esteem?
  • Mother- in most cases, other people’s opinions lower my self-esteem, but my family, especially my children, makes me feel whole again.
  • Father- I have never let anyone’s opinion lower my self-esteem. But mainly, my busy schedule might be the reason for such attitude.

Role Relationship

  • How do you discipline your children?

We engage in canning, especially when they get involved in extreme bad behaviors though that happens in rare cases.

  • How do you get involved in your family’s daily activities?

Due to my tight schedule as a father, it is always hard for every member to get engaged in the family’s daily activity.

  • How do you deal with your marital issues? Do your children realize it?

We always engage in talks since but we always try our best to never involve or let the children realize it. In that case, we always talk when they are asleep.


  • Do your beliefs and religions bar any sexual activity?

Our religion does not open-air sexual activity, raping, and prostitution.

  • How do you go about children’s sex education?

That’s a rare topic that we look forward to talking about deeply. However, at the moment, we have just engaged the children in casual talks about the dos and the don’ts of an individual and other people to them.

  • Do you have any sexual issues? How do you deal with them?

My wife always complains that I do not have enough time for her. But I always make her understand that I have to work despite being strenuous for us to survive. Though, at this moment, I am trying to look for a job that will provide my family with healthy living standards, including emotional well-being.


  • How do you cope with stress?

As a family, we designed that the most effective means to deal with stress was to talk the issue out instead of engaging in verbal or physical assaults.

  • Have you formulated any criteria to cope with the monetary crisis?

One thing that helps us cope with the monetary crisis is living within our means. When we have money, we ensure that we live to our living standards. When straining financially, we also minimize our spending to avoid loans.

  • How do you ensure that personal crisis does not disorient the family?

We overcome our issues within the shortest time possible to avoid affecting the family.