Name

Year of Birth __________________ Age _________________ Male Female

Family History (Please check all that apply)

o Alzheimers disease or dementia o Depression

o Arthritis o Heart Disease
o Asthma o High Cholesterol
o Birth defects o High Blood Pressure
o Sickle-Cell Disease o Stroke or Blood clots
o Cystic Fibrosis o Pregnancy losses, stillbirths, and
o Cancer miscarriages
o Breast o Allergies
o Colon o Peanut/Nut
o Prostate o Antibiotics
o Skin (e.g. melanoma) o Other
o Other _______________________ _______________________
o Other _______________________ o Other
_______________________
o Diabetes
o Surgery_______________________
o Blood Clotting Disorders (e.g.
o Other
hemophilia)
_____________________________
USUAL WEIGHT o Other
o Slender or average _____________________________
o 50-99 lbs. overweight
o 10-49 lbs. overweight
o Over 100 lbs. overweight DIET
o Not sure
Food preference:
ALCOHOLIC BEVERAGES Meat: Beef Pork Poultry Fish
(Beer, wine, liquor?) o Vegetables
o Regularly Sometimes o Fruits
o Never Not sure o Others _______________________
Food restrictions?_____________________
VIGOROUS EXERCISE ROUTINE at least
3times a week? Yes No Not sure Volume and type of fluid taken per day:
____________________________________
LIMITATIONS IN ACTIVITY? __________ ANY DIFFICULTY IN:
Seeing: _______________________
Hearing:___________________________
USUAL NUMBERS OF SLEEP AT NIGHT: Feeling (Touch): ____________________
o Less than four hours Tasting: ________________________
Smelling: _______________________
o 5-6 hours
o 7-8 hours
o Over 9 hours
o Not sure
Revised and retrieved from: https://familyhistory.hhs.gov/fhh-
web/home.action
 DE LA SALLE ZOBEL SCHOOL
High School Science Department

RUBRIC FOR PERFORMANCE TASK: FAMILY HEALTH PORTRAIT

NAME: CLASS NUMBER:

TEACHER: YR & SEC:

ADVANCED PROFICIENT APPROACHING DEVELOPING BEGINNING

TEACHERS
CRITERIA PROFICIENCY
RATING
(5) (4) (3) (2) (1)

Most of the
All information Very limited
All information information presented Limited information is
presented is information is
presented is is accurate, factual presented. Research
Research completely accurate, presented. Research
accurate, factual and and relevant. is not quite
Content factual, and relevant. is not satisfactory and
relevant. Research is Research is satisfactory and
(family health research Research is in-depth does not or only
in-depth and covers satisfactory and covers only some
and body systems and covers all covers few pertinent (x2)
pertinent family covers somewhat pertinent family
information) pertinent family family health
health information, pertinent family health health information,
health information, information, body
body system/s, a information, body body system/s, a
body system/s, a system/s, a specific
specific disease and system/s, a specific specific disease and
specific disease and disease and
treatment. disease and treatment.
treatment. treatment.
treatment.
Presentation is
concise, and includes
all the salient points,
and is clearly well
Presentation is
laid-out. Text is Material either includes
concise and includes Presentation is concise
too much unnecessary
written in correct and includes most of the
all the salient points. information or too little
grammar and salient points. Text has
Text is written in of the salient points. Too little information is
spelling. All relevant a few minor errors
Quality correct grammar and Text has a several presented which does
information (photos, grammar and spelling.
(overall appearance of spelling. Relevant Some relevant
errors in grammar and not support the report.
figures etc.) are spelling. Few Text has many errors
presentation) information (photos, information (photos,
appropriately information (photos, grammar and spelling.
figures etc.) are figures, etc.) are
included and properly figures, etc.) are
appropriately appropriately included (x2)
labeled, resulting in appropriately included
included and properly and properly labeled.
and properly labeled.
being a valuable
labeled.
source of information.
Some more relevant
information are
included as well.
Project shows
Project shows Project shows a quite
superior Project shows
mastery of structure unclear
understanding of adequate
and function of understanding of Project shows a very
structure and function understanding of
human systems using structure and function unclear
of human systems structure and function
appropriate terms of human systems, understanding of
using appropriate of human systems
and can be a using terms not quite structure and function
Concept terms, and can be a while using accurate
valuable source of
good source of terms, but information
accurate, with of human systems (x2)
Accuracy information that can information needing a and does not use
information that can can still be improved
be used as reference. lot of improvement. appropriate terms,
be used as reference. on. Interrelationships
Interrelationships Interrelationships with information
Interrelationships among systems are
among systems are among systems are either very unclear or
among systems are somewhat explained
clearly explained (if not quite clear (if not provided.
explained (if more (if more than one
more than one more than one
than one system is system is cited.)
system is cited). system is cited.)
cited.)

TOTAL /30

Modified and taken from: http://www.most.org/curriculum_project/Life_Sciences/high/Post/Travel_the_Body.pdf

 DE LA SALLE SANTIAGO ZOBEL SCHOOL
High School Department
Third Term, AY 2015-2016

Grade 8 Biology
Performance Task: Family Health Portrait

GOAL: You will create a family health portrait personalized to your family including a treatment plan for a specific family
disease.

ROLE: You are a student learning body systems, giving you a chance to reflect on how proper nutrition and overall
wellness affect the human body.

AUDIENCE: Family members and classmates

SITUATION: You decide to do a family health history, essentially checking on you and your familys (paternal and
maternal sides) health and lifestyle choices. Constructing your own family health portrait will enable you to identify some
medical problems common to your family, making you aware of things you may do to improve, delay or even prevent
future health problems. Your family health history portrait will become part o Your family health history portrait must be
scientific, informative and persuasive.

PERFORMANCE: You will use a program revised from the U.S. Surgeon Generals office for your family health history,
interviewing any family member directly related to you i.e. mother, father, grandfather, etc. (at most 1-2) and collate all
your data. Once you have identified at least one common family disorder, you will use your knowledge of the body
systems by researching about this particular disorder, including a lifestyle treatment plan. Your disorder must come from
any of these systems: (1) Digestive, (2) Respiratory, (3) Endocrine, (4) Nervous, and (5) Circulatory. You will construct
your family health portrait and treatment plan before presenting it to your family.

STANDARDS: Your work will be evaluated according to the following criteria: research content, quality and concept
accuracy.

SAMPLE
FAMILY HEALTH Santos Family Health HYPERTENSION
PORTRAIT FORM Portrait
(DAD)
BRIEF INFORMATION
(Include a little Which side of the family?
summary) General information about
disease etc.

TREATMENT PLAN (food,

FAMILY HEALTH medicine, lifestyle choices
PORTRAIT FORM etc.)
(MOM)
REFLECTION
(Include a little Interview pictures
summary)

- Long folder can be used as backbone. Other Options: portfolio, scrapbook, album etc. (as long as all data and pictures
are presented)

IMPORTANT:

Information provided within the family health portrait will be treated and maintained with the utmost
confidentiality.