Introduction, please tell us about yourself Name (initials only) ___________________________________

Introduction, please tell us about yourself Name (initials only) _____________________________________________________________ Age_________ Sex_________ Marital Status________________________________________________________________ Cultural Back_________on ___________Chinese America culture__________________________ Religion/ Religion Affiliation______________________________________________________ Place of Birth/ Country___________________________________________________________ Where did you Grow up? _________________________________________________________ Biocultural Variations and Cultural Aspects of the Incidence of the Disease 1. What is your family past medical history? 2. Do you have a medical history or any recent medical diagnosis that affect your current health status? 3. Do you think there are socioenvironmental conditions that may affect you or your family members, that could be more prevalent among your cultural group that can be a cause of health disparity predisposition? 4. Are there any specific distinctive features characteristics in your family, between family members or among your culture, that you may have notice to be unique and stands out? Communication 1. Do you have a native language or dialect? 2. What language do you use at home with your family? 3. What language do you prefer to communicate with? 4. How comfortable are you speaking English? Are you able to write and speak English fluently? 5. If and when you go to the hospital do you or your family require an Interpreter? Would you like to have an interpreter for you or your family members available? If so what language? Is there a preference on who interprets for you? 6. Do you have any communication impairments or disabilities that require specific accommodations? 7. What individual styles of nonverbal communication are used within your family? 8. How do you and your family feel about health care providers who are not of the same cultural or religious background? Do you prefer to receive care from a nurse of the same cultural background, gender and or age? How do you or your family members react to care providers of different cultural backgrounds, age and gender? Cultural Affiliation 1. What cultural group do you have affiliation with, it could be more than one or two? 2. What are the views of your other family members regarding cultural affiliation, do they coincide or differ from your own cultural affiliation? Cultural Sanctions and Restrictions 1. How does your cultural group regard expression of emotions and feelings, spirituality, and religious beliefs? 2. How do men and women express modesty? Are there culturally defined expectations about male and female relationships, including the nurse and client care treatment relationship? 3. Do you or your family have a preference or any restrictions related to sexuality, exposure of various parts of the body during medical exam or certain types of surgery? 4. Are there any restrictions against discussions of dead relatives or fears related to the unknown? Developmental Considerations 1. Are there any distinct growth and developmental characteristics that vary within your cultural background or family? 2. Are there any cultural age specific growth standards, for breastfeeding, toilet training, introductions of various types of foods, gender difference, discipline, and socialization to adult role? 3. Are there any specific cultural beliefs and practices associated with developmental life events such as pregnancy, birth, puberty, marriage, and death? 4. What is the cultural perception of aging? 5. How are the elderly care for within your cultural group? What are the culturally accepted roles for the elderly? Economics 1. Who is the principle wage earner in the family and what is the income level? Is there more than one wage earner? Are there other sources of financial support or assistance? 2. Does your family have medical insurance? Do you understand the coverage rates and terms of your health insurance provider policy? 3. What impact does your economic status have on your lifestyle and living conditions? 4. What has been your family experience with the health care system in terms of reimbursement, costs, and insurance coverage? Educational Background 1. What is the highest level of education you have obtain? What values did your family members express regarding educational achievements? 2. Do you understand all medical information given to you about your health care? Do know how to obtain information about your medical information, diagnostic and treatment? Do you understand written educational material given to you about your health and diagnosis? 3. What would be the best method for you to learn medical education information provided to you? What learning style is more comfortable for you?
4. Where do you rather have health related teaching sessions, in the hospital setting or away from the hospital, at your community sites like school site, adult day care center, churches etc.? Would it be better to have someone come out to your home? Health-Related Beliefs and Practices 1. Are there any special beliefs with in your family or culture that may attribute and influence beliefs of the cause of illness and disease? Is there congruence within the family on these beliefs? 2. What are your beliefs about ideal body size and shape? What is your own body self-image in relation with the ideal body size? 3. How will you describe your own health condition at this time? 4. What do you or your family member believe that promote good health? Are there any special influence by family or cultural believes? 5. What is your religious affiliation? How actively are you involved in your religious activities and practices? Do your other family members practice the same religion? Are there any special practices with in your religion such as healing prayers, healing ceremonies or prayer, into health/illness care? 6. Does your family or you rely or believe on cultural healers? If so who determines when a person is sick or ill? Who influences the choice or type of healer and treatment that should be use? 7. Are there any special type of healing or health promoting practices that you engage in? Do your family members share the same believes? 8. What is your perception on biomedical healthcare providers? What is your perception of nurses? What are your expectations of nurses and nursing care workers? 9. If you were to become ill, who will take care of you at home? What accommodations will your family members make to provide caregiving? 10. How do you, your family members and cultural group view mental health illness disorders? Are there any differences in acceptable behaviors for physical versus psychological illness? Kinship and Social Network 1. What is the composition of your family? What is the composition of a typical family within the kinship network? 2. Who is part of your social network? Do they have any influence on your health or illness status? 3. How do members of your social support network define caring or caregiving? What would be the role of your family members during health and illness episodes? Who will make decisions about health and health care? 4. How will your family members participate in the promotion of health and nursing care for you? 5. Does your cultural and family structure influence the response to health or illness? 6. What influence do ethnic, cultural and /or religious organizations have on your life style and quality of life? 7. Are there special gender issues within your cultural group? Or does your family conform with the traditional roles? Nutrition 1. What nutritional factors are influence by your cultural background? What is the meaning of food and eating to you and your family? 2. Do you or your family members have any eating disorders? What is your view about eating disorder conditions? 3. What are your usual eating routines? What are the foods that you like and enjoy? What times do you usually eat? What are your usual meal patterns? 4. What is your definition of food? What do you believe constitutes healthy and unhealthy diet? Are these beliefs congruent with what you actually eat? 5. Who usually shops for and choose food? Where are the foodstuffs purchased? Who prepares the actual meals? How are your family members involved in nutritional choices, values, and choices about food? 6. How is your food prepared at home? Who does the food preparations? 7. Have you chosen any particular nutritional practices? Do your other family members adhere these beliefs and practices? 8. Do religious beliefs of or practices influence you or your familys diet, preparation or delineation of acceptable food combinations? Do you or your family abstain from certain foods at regular intervals, on specific dates determined by religious calendar, or at other times? Are there other food prohibitions or prescriptions? 9. Does your religion mandate or encourage fasting? If so for what period of time? Are there exceptions to fasting? 10. During meal times do you or your family use special utensils? 11. Do you or your family use home and folk remedies to treat illness? Which over the counter medications are used? Religion and Spirituality 1. How does your familys religious affiliation affect health and illness? 2. What are the role of religious beliefs and practices during health and illness? Are there any special rites or blessings for those with serious or terminal illnesses? 3. Are there any healing rituals or practices that the client and family believe can promote well-being or hasten recovery from illness? If so, who performs these? What materials or arrangements are necessary for the nurse to have available for the practice of these rituals? 4. What is the role of significant religious representatives during health and illness? Are there recognized as religious healers? Values Orientation 1. What is your attitude, values, and beliefs about your health and illness status? Do your family members have similar values and beliefs? 2. How do you feel this influence behavior in terms of promotion of health and treatment of illness/disease? What are the values, beliefs and attitudes that you and your family have about health care providers? 3. Does culture affect the manner in which you relate to body image change resulting from illness or surgery? Is there a cultural stigma associated with an illness and the way it was contracted? 4. How do you and your family view, work, leisure and education? 5. How do you perceive and react to change? 6. How do you perceive changes in lifestyles related to current illness and surgery? 7. How do you and your family view biomedical health care? 8. How do you value privacy, courtesy, touch, and relationship with others? 9. How do you relate to others outside your cultural group?

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