heritage assessment
Note: The greater the number of positive responses, the greater the
person’s identification with a traditional heritage. The one exception
to positive answers is the question about family name change. This
question may be answered negatively.
1. Where was your mother born?____________________________
2. Where was your father born? ______________________________
3. Where were your grandparents born?
(1) Your mother’s mother?______________________________
(2) Your mother’s father? ______________________________
(3) Your father’s mother? ______________________________
(4) Your father’s father? ________________________________
4. How many brothers _____ and sisters _____ do you have?
5. What setting did you grow up in? Urban _____ Rural _____
Suburban _____
6. What country did your parents grow up in?
Father _____
Mother _____
7. How old were you when you came to the United States? _____
8. How old were your parents when they came to the United
States? Mother _____ Father _____
9. When you were growing up, who lived with you? _____
10. Have you maintained contact with
a. Aunts, uncles, cousins? (1) Yes _____ (2) No _____
b. Brothers and sisters? (1) Yes _____ (2) No _____
c. Parents? (1) Yes _____ (2) No _____
d. Your own children? (1) Yes _____ (2) No _____
11. Did most of your aunts, uncles, cousins live near your home?
(1) Yes _____ (2) No _____
12. Approximately how often did you visit your family members who
lived outside your home?
(1) Daily _____ (2) Weekly _____ (3) Monthly _____ (4) Once
a year or less _____ (5) Never _____
13. Was your original family name changed?
(1) Yes _____ (2) No _____
14. What is your religious preference?
(1) Catholic _____ (2) Jewish _____ (3) Protestant _____
(4) Denomination (5) Other _____ (6) None _____
15. Is your spouse the same religion as you?
(1) Yes _____ (2) No _____
16. Is your spouse the same ethnic background as you?
(1) Yes _____ (2) No _____
17. What kind of school did you go to?
(1) Public _____ (2) Private _____ (3) Parochial _____
18. As an adult, do you live in a neighborhood where the neighbors
are the same religion and ethnic background as yourself?
(1) Yes _____ (2) No _____
19. Do you belong to a religious institution?
(1) Yes _____ (2) No _____
20. Would you describe yourself as an active member?
(1) Yes _____ (2) No _____
21. How often do you attend your religious institution?
(1) More than once a week _____ (2) Weekly _____
(3) Monthly _____ (4) Special holidays only _____
(5) Never _____
22. Do you practice your religion at home?
(1) Yes _____ (2) No _____
(If yes, please specify)
(3) Praying _____ (4) Bible reading _____
(5) Diet _____ (6) Celebrating religious holidays _____
23. Do you prepare foods of your ethnic background?
(1) Yes _____ (2) No _____
24. Do you participate in ethnic activities?
(1) Yes _____ (2) No _____
(If yes, please verify)
(3) Singing _____ (4) Holiday celebrations _____
(5) Dancing _____ (6) Festivals _____
(7) Costumes _____ (8) Other _____
25. Are your friends from the same religious background as you?
(1) Yes _____ (2) No _____
26. Are your friends from the same ethnic background as you?
(1) Yes _____ (2) No _____
27. What is your native language? _____
28. Do you speak this language?
(1) Prefer _____ (2) Occasionally _____ (3) Rarely _____
29. Do you read your native language?
(1) Yes _____ (2) No _____
B O X 6 – 1 Heritage Assessment Tool
Source: Spector, R. E. (2000). CulturalCare: Guide to heritage assessment and health traditions (5th ed.). Pearson Education/PH College.
CAUCASIAN/WHITE
1. Where was your mother born. Philadelphia____________________________
2. Where was your father born? Bellows Falls, VT___________________________
3. Where were your grandparents born?
(1) Your mother’s mother?Philadelphia___________________________
(2) Your mother’s father? Athens , OH___________________________
(3) Your father’s mother? Montague, PEI Canada____________________________
(4) Your father’s father? _IDK_______________________________
4. How many brothers _____ and sisters __2___ do you have?
5. What setting did you grow up in? Urban _____ Rural _____
Suburban ___x__
6. What country did your parents grow up in?
Father USA__
Mother USA____
7. How old were you when you came to the United States? __NA___
8. How old were your parents when they came to the United
States? Mother __NA___ Father __NA___
9. When you were growing up, who lived with you? __Father's mother___
10. Have you maintained contact with
a. Aunts, uncles, cousins? (1) Yes __x___ (2) No _____
b. Brothers and sisters? (1) Yes __they are dead___ (2) No _____
c. Parents? (1) Yes __they are dead___ (2) No _____
d. Your own children? (1) Yes __x___ (2) No _____
11. Did most of your aunts, uncles, cousins live near your home?
(1) Yes _____ (2) No ___x__
12. Approximately how often did you visit your family members who
lived outside your home?
(1) Daily _____ (2) Weekly _____ (3) Monthly _____ (4) Once
a year or less __x___ (5) Never _____
13. Was your original family name changed?
(1) Yes _____ (2) No ___x__
14. What is your religious preference?
(1) Catholic _____ (2) Jewish _____ (3) Protestant ____x_
(4) Denomination (5) Other ___quaker__ (6) None _____
15. Is your spouse the same religion as you?
(1) Yes _____ (2) No __x___
16. Is your spouse the same ethnic background as you?
(1) Yes ___x__ (2) No _____
17. What kind of school did you go to?
(1) Public _____ (2) Private ___x__ (3) Parochial _____
18. As an adult, do you live in a neighborhood where the neighbors
are the same religion and ethnic background as yourself?
(1) Yes _____ (2) No _____
19. Do you belong to a religious institution?
(1) Yes _____ (2) No _____
20. Would you describe yourself as an active member?
(1) Yes ___x__ (2) No _____
21. How often do you attend your religious institution?
(1) More than once a week _____ (2) Weekly _____
(3) Monthly _____ (4) Special holidays only _____
(5) Never ___x__
22. Do you practice your religion at home?
(1) Yes _____ (2) No ___x__
(If yes, please specify)
(3) Praying _____ (4) Bible reading _____
(5) Diet _____ (6) Celebrating religious holidays _____
23. Do you prepare foods of your ethnic background?
(1) Yes _____ (2) No __x___
24. Do you participate in ethnic activities?
(1) Yes _____ (2) No _x____
(If yes, please verify)
(3) Singing _____ (4) Holiday celebrations _____
(5) Dancing _____ (6) Festivals _____
(7) Costumes _____ (8) Other _____
25. Are your friends from the same religious background as you?
(1) Yes _____ (2) No ___x__
26. Are your friends from the same ethnic background as you?
(1) Yes ___mixed__ (2) No _____
27. What is your native language? __english___
28. Do you speak this language?
(1) Prefer _____ (2) Occasionally _____ (3) Rarely ___x__
29. Do you read your native language?
(1) Yes __x___ (2) No _____
1.Ontario, CA
2. Bourne, MA
3. Unknown for all parts
4. 1 brother, 1 sister
5. Urban
6. United States, United States
7. Born here
8. Born here
9. Parents, siblings, niece
10. A) only cousins, only brother C) yes D) n/a
11. No
12. Never
13. No
14. None
15. N/A
16. N/A
17. Public
18. No
19. No
20. N/A
21. N/A
22. N/A
23. Yes
24. No
25. No
26. No
27. English
28. Prefer
29. Yes
AFRICAN AMERICAN CULTURE/BACKGROUND
1.Los Angeles
2.Kansas city
3. 1.Mississippi .2.Kansas city. 3.Arkansas. 4.Kansas city 4. 7 brother's. 5 sister
5.all three.
6. 1.USA. 2.USA. 3 USA
7.was borne in the USA 8.mom dad borne also in the USA.
9.mother and all most of my siblings. 10.yes...a.yes..b.yes.c.yes.
12.once a year.
13.no
14.other
15.yes
16.yes
17.public
18.no
19.yes
20.not anymore
21.special holiday
22.yes
23.yes
24.yes ..5 dancing
25.yes
26.some
27.English
28.prefer
29. English.
