This document contains a template for formulating a family care plan. It includes sections for collecting identifying data on family members, creating a family genogram, assessing individual health needs, interpersonal needs, family needs including developmental stages, illnesses/losses, resources and support, environment, and internal family dynamics. The final section is for analyzing the family style, strengths, and functioning and identifying needs. The overall purpose is to gather comprehensive information on a family to develop a tailored care plan.

1. Formulating a Family Care Plan
I Identifying Data
· Name:
_____________________________________________________
_____________________________________________
· Address:
_____________________________________________________
_____________________________________________
· Phone
number(s):____________________________________________
_________________________________________________
· Household members (relationship, gender, age, occupation,
education):___________________________________________
_________
· Financial data (sources of income, financial assistance,
medical care;
expenditures):_________________________________________
__
· Ethnicity:
_____________________________________________________
_____________________________________________
· Religion:
_____________________________________________________
_____________________________________________
· Identified
client(s):_____________________________________________
_________________________________________________
· Source of referral and reason:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

2. _____________________________________________________
_____________________________________
II Genogram
· Include household members, extended family, and significant
others
· Age or date of birth, occupation, geographical location,
illnesses, health problems, major events
· Triangles and characteristics of relationships
III Individual Health Needs (for each household family member)
· Identified health problems or concerns:
_____________________________________________________
___________________________
· Medical diagnoses:
_____________________________________________________
________________________________________
· Recent surgery or hospitalizations:
_____________________________________________________
____________________________
· Medications and immunizations:
_____________________________________________________
____________________________
· Physical assessment data:
_____________________________________________________
_________________________________
· Emotional and cognitive functioning:
_____________________________________________________
__________________________
· Coping:
_____________________________________________________
________________________________________________
· Sources of medical and dental care:
_____________________________________________________
_______________________
· Health screening practices:
_____________________________________________________
_______________________________

3. IV Interpersonal Needs
· Identified subsystems and
dyads:_______________________________________________
_________________________________
· Prenatal care needed:
_____________________________________________________
____________________________________
· Parent–child
interactions:__________________________________________
_____________________________________________
· Spousal
relationships:_________________________________________
________________________________________________
· Sibling
relationships:_________________________________________
________________________________________________
· Concerns about older
members:_____________________________________________
______________________________________
· Caring for other dependent
members:_____________________________________________
___________________________________
· Significant
others:_______________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_________________________________________________
V Family Needs
· A. Developmental
· Children and
ages:________________________________________________
____________________________________________
· Responsibilities for other members:
_____________________________________________________

4. ________________________
· Recent additions or loss of
members:_____________________________________________
________________________________
· Other major normative transitions occurring
now:_________________________________________________
___________________
· Transitions that are out of sequence or
delayed:______________________________________________
_______________________
· Tasks that need to be
accomplished:_________________________________________
______________________________________
· Daily health-promotion practices for nutrition, sleep, leisure,
child care, hygiene, socialization, transmission of norms and
values:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_________________
· Family planning
used:________________________________________________
_______________________________________
· B. Loss or Illness
· Nonnormative events or
illnesses:_____________________________________________
_________________________________
· Reactions and perceptions of ability to
cope:________________________________________________
________________________
· Coping behaviors used by individuals and family
unit:_________________________________________________
________________
· Meaning to the
family:_______________________________________________

5. __________________________________________
· Adjustments family has
made:________________________________________________
________________________________
· Roles and tasks being assumed by
members:__________________________ ___________________
____________________________
· Any one individual bearing most of
responsibility:_________________________________________
____________________________
· Family idea of alternative coping behaviors
available:______________________________ _______________
_______________________
· Level of anxiety now and
usually:______________________________________________
___________________________________
· C. Resources and Support
· General level of resources and economic exchange with
community:___________________________________________
______________
· External sources of instrumental support (money, home aides,
transportation, medicines,
etc.):____________________________________
· Internal sources of instrumental support (available from
family
members):____________________________________________
_______
· External sources of affective support (emotional and social
support, help with problem
solving):_____________________________________
· Internal sources of affective support (who in family is most
helpful to whom?):
_________________________________________________
· Family more open or closed to
outside?______________________________________________
________________________________

6. · Family willing to use external sources of
support?______________________________________________
_________________________
· D. Environment
· Type of
dwelling:_____________________________________________
___________________________________________________
· Number of rooms, bathrooms, stairs; refrigeration,
cooking:_____________________________________________
__________________
· Water and
sewage:______________________________________________
________________________________________________
· Sleeping
arrangements:_________________________________________
____________________________________________________
· Types of jobs held by
members:_____________________________________________
__________________________________________
· Exposure to hazardous conditions at
job:_________________________________________________
__________________________
· Level of safety in the
neighborhood:_________________________________________
___________________________________________
· Level of safety in
household:____________________________________________
____________________________________________
· Attitudes toward involvement in
community:___________________________________________
________________________________
· Compliance with rules and laws of
society:______________________________________________
______________________
· How are values similar to and different from those of the
immediate social

7. environment?_____________________________________
· E. Internal Dynamics
· Roles of family members clearly
defined?______________________________________________
________________________
· Where do authority and decision making
rest?_________________________________________________
____________________
· Subsystems and
members:_____________________________________________
_____________________________________
· Hierarchies, coalitions, and
boundaries:___________________________________________
_____________________________
· Typical patterns of
interaction:___________________________________________
____________________________________
· Communication, including verbal and
nonverbal:____________________________________________
______________________
· Expression of affection, anger, anxiety, support,
etc.:_________________________________________________
_______________
· Problem-solving
style:________________________________________________
________________________________________
· Degree of cohesiveness and loyalty to family
members:_____________________________________________
_____________________________________________________
_____________________________________________________
____________________
· Conflict
management:__________________________________________
______________________________________________
_____________________________________________________
_____________________________________________________

8. VI Analysis
· Identification of family
style:________________________________________________
__________________________________
· Identification of family
strengths:_____________________________________________
________________________________
· Identification of family
functioning:___________________________________________
_________________________________
· What are needs identified by family?
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_________________
· What are needs identified by community/public health
nurse?_______________________________________________
_____________________________________________________
_____________________________________________________
_____
Formulating a Family Care Plan
I Identifying Data
· Name:
_____________________________________________________
_____________________________________________
· Address:
_____________________________________________________
_____________________________________________
· Phone
number(s):____________________________________________
_________________________________________________
· Household members (relationship, gender, age, occupation,

9. education):___________________________________________
_________
· Financial data (sources of income, financial assistance,
medical care;
expenditures):_________________________________________
__
· Ethnicity:
_____________________________________________________
_____________________________________________
· Religion:
_____________________________________________________
_____________________________________________
· Identified
client(s):_____________________________________________
_________________________________________________
· Source of referral and reason:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________
II Genogram
· Include household members, extended family, and significant
others
· Age or date of birth, occupation, geographical location,
illnesses, health problems, major events
· Triangles and characteristics of relationships
III Individual Health Needs (for each household family member)
· Identified health problems or concerns:
_____________________________________________________
___________________________
· Medical diagnoses:
_____________________________________________________

10. ________________________________________
· Recent surgery or hospitalizations:
_____________________________________________________
____________________________
· Medications and immunizations:
_____________________________________________________
____________________________
· Physical assessment data:
_____________________________________________________
_________________________________
· Emotional and cognitive functioning:
_____________________________________________________
__________________________
· Coping:
_____________________________________________________
________________________________________________
· Sources of medical and dental care:
_____________________________________________________
_______________________
· Health screening practices:
_____________________________________________________
_______________________________
IV Interpersonal Needs
· Identified subsystems and
dyads:_______________________________________________
_________________________________
· Prenatal care needed:
_____________________________________________________
____________________________________
· Parent–child
interactions:__________________________________________
_____________________________________________
· Spousal
relationships:_________________________________________
________________________________________________
· Sibling

11. relationships:_________________________________________
________________________________________________
· Concerns about older
members:_____________________________________________
______________________________________
· Caring for other dependent
members:_____________________________________________
___________________________________
· Significant
others:_______________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_________________________________________________
V Family Needs
· A. Developmental
· Children and
ages:________________________________________________
____________________________________________
· Responsibilities for other members:
_____________________________________________________
________________________
· Recent additions or loss of
members:_____________________________________________
________________________________
· Other major normative transitions occurring
now:_________________________________________________
___________________
· Transitions that are out of sequence or
delayed:______________________________________________
_______________________
· Tasks that need to be
accomplished:_________________________________________
______________________________________
· Daily health-promotion practices for nutrition, sleep, leisure,

12. child care, hygiene, socialization, transmission of norms and
values:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_________________
· Family planning
used:________________________________________________
_______________________________________
· B. Loss or Illness
· Nonnormative events or
illnesses:_____________________________________________
_________________________________
· Reactions and perceptions of ability to
cope:________________________________________________
________________________
· Coping behaviors used by individuals and family
unit:_________________________________________________
________________
· Meaning to the
family:_______________________________________________
__________________________________________
· Adjustments family has
made:________________________________________________
________________________________
· Roles and tasks being assumed by
members:__________________________ ___________________
____________________________
· Any one individual bearing most of
responsibility:_________________________________________
____________________________
· Family idea of alternative coping behaviors
available:______________________________ _______________
_______________________
· Level of anxiety now and

13. usually:______________________________________________
___________________________________
· C. Resources and Support
· General level of resources and economic exchange with
community:___________________________________________
______________
· External sources of instrumental support (money, home aides,
transportation, medicines,
etc.):____________________________________
· Internal sources of instrumental support (available from
family
members):____________________________________________
_______
· External sources of affective support (emotional and social
support, help with problem
solving):_____________________________________
· Internal sources of affective support (who in family is most
helpful to whom?):
_________________________________________________
· Family more open or closed to
outside?______________________________________________
________________________________
· Family willing to use external sources of
support?______________________________________________
_________________________
· D. Environment
· Type of
dwelling:_____________________________________________
___________________________________________________
· Number of rooms, bathrooms, stairs; refrigeration,
cooking:_____________________________________________
__________________
· Water and
sewage:______________________________________________
________________________________________________
· Sleeping

14. arrangements:_________________________________________
____________________________________________________
· Types of jobs held by
members:_____________________________________________
__________________________________________
· Exposure to hazardous conditions at
job:_________________________________________________
__________________________
· Level of safety in the
neighborhood:_________________________________________
___________________________________________
· Level of safety in
household:____________________________________________
____________________________________________
· Attitudes toward involvement in
community:___________________________________________
________________________________
· Compliance with rules and laws of
society:______________________________________________
______________________
· How are values similar to and different from those of the
immediate social
environment?_____________________________________
· E. Internal Dynamics
· Roles of family members clearly
defined?______________________________________________
________________________
· Where do authority and decision making
rest?_________________________________________________
____________________
· Subsystems and
members:_____________________________________________
_____________________________________
· Hierarchies, coalitions, and
boundaries:___________________________________________
_____________________________

15. · Typical patterns of
interaction:___________________________________________
____________________________________
· Communication, including verbal and
nonverbal:____________________________________________
______________________
· Expression of affection, anger, anxiety, support,
etc.:_________________________________________________
_______________
· Problem-solving
style:________________________________________________
________________________________________
· Degree of cohesiveness and loyalty to family
members:_____________________________________________
_____________________________________________________
_____________________________________________________
____________________
· Conflict
management:__________________________________________
______________________________________________
_____________________________________________________
_____________________________________________________
VI Analysis
· Identification of family
style:________________________________________________
__________________________________
· Identification of family
strengths:_____________________________________________
________________________________
· Identification of family
functioning:___________________________________________
_________________________________
· What are needs identified by family?
_____________________________________________________
_____________________________________________________
_____________________________________________________

16. _____________________________________________________
_____________________________________________________
_________________
· What are needs identified by community/public health
nurse?_______________________________________________
_____________________________________________________
_____________________________________________________
_____