Please note: any questions that you feel you cannot answer for any reason, you do not have to answer. Your real name will not be given out, in fact, I will just be stating "RG" in the final report.
The purpose of the assignment is to show how stereotyping can occur and how, as healthcare workers in America, should be reacting to people of different cultures. There is a movement going on where most of us should be "culturally adept" and should be able to react properly and be culturally sensitive. Basically put, remember not to touch a Thai immigrant on the head, keep contact with an east-indian female, ect.

Cultural Assessment Questionnaire*
Communication
1.   Do you speak English as your primary language?
•	Do you speak another language at home? 
•	Do you read English? Do you read another language? 
•	Do you understand common medical terms such as pain, fever, and nausea? 
•	Is there a family member to interpret when the hospital (agency) interpreter may not be available? 
2.  Orientation or Cultural Affiliation
•	Where were you born? 
•	How long have you lived in the United States? 
•	Were your parents born in the United States? 
•	How long have your parents lived in the United States? 
•	Do you or your parents still follow the traditions of your native land (or culture)? 
3.  Nutrition
•	Do you prefer certain foods (vegetarian diet, diet free from pork)? 
•	Should food be prepared in a certain way (no fried foods)? 
•	Do you want family members to bring in specific foods? 
•	Do you abstain from any foods? Do you abstain for religious reasons or for health reasons? 
•	How often do you prefer to eat? 
•	With whom do you usually share your meals? 
•	What utensils do you prefer to use? 
•	Are there any foods or drinks that help you to feel better when you are ill? 

4.  Religious Affiliation
•	Do you have religious objects (Bible, amulets) that you want to keep with you during an examination? 
•	Do you belong to a church group or other religious affiliation? 
•	Do you wear clothing with a religious significance (prayer shawl, garment, or cross)? 
•	Do you normally pray at certain times during the day? 
•	Do you observe the Sabbath? 
•	Are there any spiritual practices that help you feel better (prayer, meditation, reading scriptures, watching religious programs on television? 
•	Do you consult a religious healer? 
•	Does your religious faith restrict any specific food or drink? 
•	Do you fast or refrain from eating certain foods at certain times of the day, week, or month? 
•	Are you excused from fasting when ill? 

5.  Family Relationships
•	Who are the members of your immediate or nuclear family? 
•	Do you have extended family; in other words, aunts, uncles, cousins, nephew, nieces? 
•	Who is the head of the household? 
•	Who manages the financial matters within you household? 
•	Where do you and your family live?  In the city or the suburbs? 
•	What do you and your family do together for recreation? 
•	Do you have family members who will help during times of illness? 
•	Who will take over you duties if you are too ill to perform them during an illness? 

6.	Educational Background
•	What is the last grade or degree that you completed in school?
•	Did you go to school primarily in the United States or elsewhere?
•	Are there any subjects that you have studied outside of school?
•	Are you or your family acquainted with medical terminology? 
•	Do you learn best from written materials, audiovisual materials, or from a hands-on approach? 
7.  Occupation and Socioeconomic Status
•	What type of work do you do? 
•	Does anyone else in your family work? 
•	Do you or your spouse have benefits such as health and dental insurance? Do you receive paid sick days, and if so, how many per year? 
8.  Health Beliefs
•	What do you do to stay healthy? 
•	What do you feel is a healthy diet? Do you try to follow this diet? 
•	What do you do for exercise? 
•	Is there anything else that you do to stay healthy? 
•	Except for this current illness, do you feel that you are reasonably healthy? What do you think are the major reasons people become ill? 
•	Why do you think you have become ill? 
9.  Hospital Experiences
•	Have you ever been hospitalized before? 
•	When were you hospitalized? 
•	Where were you hospitalized? 
•	What was your hospitalization like? 
•	Is there anything that can be done to make a hospitalization easier for you? 
10.  Personal Care
•	Do you prefer to bathe in the morning or the evening? 
•	Should the nurse follow any special order or routine? 
•	Do you prefer a family member to assist with your personal care? 
•	Do you prefer to do as much of your personal care as possible? 

*  Adapted from: Luckmann, Joan, Transcultural Communication in Health Care, Delmar, 2000