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Session 1 - Knowledge Is Power: Know Your Risk for Heart Disease

Objectives

By the end of this session, group members will:

  • Know about the With Every Heartbeat Is Life project.
  • Know how the heart works and its importance.
  • Know that heart disease can be prevented.
  • Be able to name six risk factors for heart disease that can be prevented.
  • Know their family risk of heart disease.
  • Know other group members.

Materials and Supplies

To conduct this session, you will need:

  • "With Every Heartbeat Is Life" manual and picture cards
  • Name tags
  • Hearts cut from red felt (try to get the kind that has a sticky backing) or red construction paper. Use the shape to cut out the heart.
  • Safety pins (if not using felt with sticky backing)
  • Blackboard and chalk or several large pieces of paper, a marker, and tape
  • Clear container that is filled with 4 cups of water

Handouts

Give each group member these handouts during this session:

Session Outline

Introducing the Session

  1. Welcome
  2. Project Overview
  3. Project Rules

Conducting the Session

  1. Getting To Know Each Other
  2. Getting To Know the Secrets of the Heart
    1. How the Heart Works
    2. The Heart's Structure
  3. Facts About Heart Disease
  4. Risk Factor Activity
  5. Family Health History Activity

Review of Today's Key Points

Closing

Note: Read the "More Information" chart to be ready to answer questions from group members.


Introducing the Session

  1. Welcome
    • Introduce yourself as people walk in.
    • Ask each person his or her name. Write it on a name tag. Give each person a name tag and a felt or paper heart.
    • Ask group members to wear the name tags on their shirts. Ask them to place the felt or paper hearts where their own hearts are found.
    • Welcome group members to the session. Tell them that you are very happy to see them.
    • Say:
      I want to start today's discussion with a quote from Rev. Jesse Jackson. He said, "If my mind can conceive it, and my heart can believe it, I know I can achieve it."
    • Ask:
      What does this quote mean to you?
      Note: Allow 2 or 3 minutes for group members to respond.
    • Say:
      These classes will prepare you to live heart healthy today and into your future—your tomorrow! I congratulate you on taking this step for your health!
  2. Project Overview
    • Say:
      Heart disease is the #1 reason why people die in this country. The National Heart, Lung, and Blood Institute (NHLBI), part of the NIH, created the With Every Heartbeat Is Life project to help African Americans prevent heart disease.
    • Say:
      We know that knowledge is power. Knowing whether you are at risk for heart disease can empower you with the ability to do something about it. Together, we will empower ourselves by learning about the risk factors for heart disease. We also will learn things you and your family can do to have healthy hearts.
    • Say:
      This heart health education program has 12 sessions and an optional grocery store tour. Session 12 explains evaluation and is only for community health workers. The sessions cover these topics.
    • Show the names of the sessions on the blackboard or on a large piece of paper taped to the wall.
      1. "Knowledge Is Power: Know Your Risk for Heart Disease"
      2. "Act in Time to Heart Attack Signs"
      3. "Get Energized! Say YES to Physical Activity"
      4. "Help Your Heart: Control Your High Blood Pressure"
      5. "Be Heart Smart: Keep Your Cholesterol in Check"
      6. "Embrace Your Health! Aim for a Healthy Weight"
      7. "Protect Your Heart: Take Good Care of Your Diabetes for Life"
      8. "Make Heart Healthy Eating an Everyday Family Reunion"
      9. "Eat in a Heart Healthy Way—Even When Time or Money Is Tight"
      10. "Take Control of Your Health: Enjoy Living Smoke Free"
      11. "Review and Graduation"
      12. "Use Evaluation To Track Your Progress (Especially for Community Health Workers)"
    • Say:
      Please come to all of the sessions. I will lead the sessions, but I need each of you to participate. This will help you learn the information and enjoy the sessions more. Please feel free to ask questions. Your questions also help others to learn.
    • Give each group member the "Introducing the Harris Family of the 'With Every Heartbeat Is Life' Manual" handout. Ask for a volunteer to read it aloud.
    • Show picture card 1.1.
    • Say:
      The Harris family members will appear throughout this manual to show how they are adopting healthy lifestyles.
  3. Project Rules
  4. Note: This section will help group members feel like a team. It also will make it easier for you to lead the sessions.
    • Say:
      Everyone will feel more at ease if they know what to expect from the training. Before we begin, let's talk about the best way to run the sessions. Let's agree as a group on a few basic rules.
    • Say:
      This course takes effort and time from each group member. It is important for you to attend each session and to arrive on time. Each of the sessions is about 2 hours long.
    • (Optional, if you are able to make changes) Ask:
      • How often do you want to meet (once a week, twice a week, etc.)?
      • Is this a good time to meet?
      Note: If not, set a meeting time that is best for most of the group.
    • Ask:
      Is this a good place to meet?
      Note: If not, decide on a location that is best for most of the group.
      Note: Allow 2 or 3 minutes for group members to answer each question. Help them choose one answer that most people like. Go on to the next question.
    • Say:
      Here are some things you can do to help you learn the most from the sessions.
      1. Feel free to ask questions.
      2. Share your personal experiences. This will make the program mean more to all of us.
      3. Try to stay on the subject. We have a lot of information to talk about in a short time.
      4. (Optional) Call me at [telephone number] if you have questions or concerns about this course. I am here to help you in any way that I can.
    • Say:
      Because you will share your experiences and opinions, we need to agree on a few things. Say "yes" if you agree to the following questions.
    • Ask:
      • Do you agree to keep other group members' comments to yourself?
      • Do you agree not to judge others?
      • Do you agree to try to come to all of the sessions?
    • Ask:
      • Do you have other rules that you would like to talk about?
      Note: Allow a moment for group members to respond.

Conducting the Session

  1. Getting To Know Each Other
    • Say:
      We'll begin today's session by introducing ourselves and getting to know each other a little better.
    • Ask group members to:
      • Give their names and tell one or two things about themselves.
      • Tell why they came to this class and what they hope to learn.
    • Note: Start this activity by going first. Tell the group why you are interested in heart health. Be honest and talk about your own personal experience. Give each group member a chance to answer.
    • Say:
      You can help your family and friends by giving them information and encouraging them to live healthier lives. Thank you for making this effort.
  2. Getting To Know the Secrets of the Heart
    • Say:
      Now that we know a little bit about each other, let's get to know a few facts about the heart.
    1. How the Heart Works
    • Say:
      The heart is an amazing part of the body. It pumps approximately 5 liters of blood every minute. It beats about 100,000 times a day.
    • Note: Hold up a clear container that has 1 liter (about 4 cups) of water in it. Remind the group that the heart pumps five times this amount of blood each minute.
    • Say:
      The heart sends blood to the lungs to pick up oxygen. Then it delivers oxygen to all the cells in the body.
    • Say:
      You can feel the beat of your heart by taking your pulse. To find your pulse, gently place the index and middle fingers of one hand on the inside wrist of your other hand. Slide your two fingers toward the thumb side of your wrist until you feel a slight heartbeat.
    • Show group members how to do this.
    1. The Heart's Structure
    • Show picture card 1.2.
    • Say:
      The heart is a hollow, muscular, cone-shaped organ, about the size of a fist.
    • Hold up your fist for the group members to see.
    • Point out each part of the heart on the picture card.
    • Say:
      • The heart has two upper chambers and two lower chambers.
      • The upper chambers (right atrium and left atrium) receive blood.
      • The lower chambers (right ventricle and left ventricle) pump blood.
    • Show picture card 1.3.
    • Say:
      • The heart is located in the middle of the chest. Did you place your felt or paper heart in the correct spot?
      • The heart is one of three main components of the circulatory system. The others are blood vessels and the blood.
      • The circulatory system is very important for sustaining life. It is made of all the vessels that carry the blood throughout the body.
      • Blood vessels are long, hollow tubes of tissue, much like drinking straws. There are various kinds of blood vessels. The main ones are called arteries (shown in red), veins (shown in blue), and capillaries (not shown).
      • The circulatory system delivers oxygen and nutrients to cells in your body and removes carbon dioxide and other waste products.
    • Show picture card 1.4.
    • Note: Point to each vein and artery. Describe the following two steps while pointing to pictures 1 and 2.
    • Say: Let's go over the major veins and arteries.
      • Blood (with little oxygen) enters the right top chamber of the heart through the largest veins in your body. These veins are called the superior and inferior vena cava.
      • Blood then flows down to the right lower chamber so it can be pumped out to the lungs through the pulmonary arteries. In the lungs, waste (carbon dioxide) is removed from the blood. The blood then gathers more oxygen.
    • Show picture card 1.5.
    • Note: Point to each vein and artery. Describe the two steps while pointing to pictures 3 and 4.
    • Say:
      • The blood, rich with oxygen, returns to the heart and enters the upper left chamber through the pulmonary vein. The blood then flows down to the lower left chamber and is pumped out of the aorta to the rest of your body. Your left and right coronary arteries carry oxygen-rich blood to all parts of your heart.
      • Heart disease is a condition that affects the heart muscle, heart valves, or the vessels of the heart. The major form of heart disease is coronary heart disease. Because the heart is such an important organ, you want to keep it free from heart disease. With every heartbeat is life. When the heart stops, life stops. So when you take care of your heart, you take care of your life
  3. Facts About Heart Disease
  • Note: Before the session, read the "More Information" chart. This chart lists the risk factors for heart disease that you can do something about. It offers you steps you can take to prevent or lower those risk factors.
  • Say:
    Now that we know how important the heart is, let's talk about heart disease and what we can do to protect our hearts.
  • Ask:
    Do you know someone who has heart disease?
  • Note: Allow about 2 minutes for group members to respond.
  • Show picture card 1.6.
  • Say:
    Heart disease is a serious health problem for African Americans.
    • It is the number one cause of death among African Americans in the United States.
    • About one out of four deaths among African Americans is due to heart disease.
    • The rate of death from heart disease is 31 percent higher among African Americans than among whites.
    • Some people believe that a heart attack or stroke happens suddenly because of a scary experience, getting bad news, stress caused by work, family problems, worries, or having strong feelings, such as anger.
    • A heart attack or stroke may seem sudden, but the truth is that heart disease happens over many years. Often it starts when you are very young.
    • Taking steps to prevent heart disease is important at any age. Taking these steps is like performing regular service on a car, such as changing the oil and checking the fluids and tires. Car maintenance helps keep the engine running smoothly so that the car won't break down on the road. In the same way, you need to take steps to care for your body so you can lower your chances of getting heart disease.
    • This course will show you the steps you and your family can take to have healthier hearts.
  • Show picture card 1.7.
  • Say:
    In every session, you will hear about something called risk factors. Risk factors are traits or habits that make a person more likely to get heart disease. Some risk factors—such as age, family history, and gender—are things you cannot change. But the good news is that you can do something about some risk factors:
    • High blood pressure
    • High blood cholesterol
    • Cigarette smoking
    • Diabetes
    • Overweight
    • Physically inactive
  1. Risk FactorActivity
    • Give each group member the "Are You at Risk for Heart Disease?" handout. Read aloud each risk factor. As you read each one, ask group members to check off the risk factors they have.
    • Say:
      The more risk factors you have checked, the greater your risk for heart disease and stroke. Talk to your doctor about your risk.
    • Say:
      This session will explain how these risk factors affect the health of the heart. It also will teach you ways that you and your family can prevent or control them, such as:
      • Lose weight if you are overweight.
      • Be physically active.
      • Cut down on salt and sodium.
      • Eat foods that are lower in saturated fat and trans fat.
      • Eat more fruits, vegetables, and low-fat milk and milk products.
      • Get your blood pressure, blood cholesterol, and blood glucose (blood sugar) levels checked.
      • Take prescribed medications as your doctor tells you.
      • Quit smoking.
    • (Optional) Note: You can share information on The Heart Truth campaign described in the Appendix.

    More Information

    Heart Disease Risk Factors You Can Do Something About
    Risk Factors Facts You Need To Know Take These Steps To Prevent Heart Disease
    High blood pressure
    High blood pressure, or hypertension, is called the "silent killer" because it often has no symptoms, yet it can cause very serious illness.

    When your blood pressure is high, your heart works harder than it should to move blood to all parts of the body. If not treated, high blood pressure can lead to stroke (brain attack), heart attack, eye and kidney problems, and death.

    Check your blood pressure numbers (mmHg*)
    Level Systolic Diastolic
    Normal Less than 120 Less than 80
    Prehypertension 120—139 80—89
    High Blood Pressure 140 or higher 90 or higher

    * Millimeters of mercury
    • Check your blood pressure once a year. Check it more often if you have high blood pressure.
    • Aim for a healthy weight.
    • Be physically active.
    • Choose and prepare foods with less salt and sodium.
    • Eat more fruits, vegetables, and low-fat milk products.
    • If you drink alcohol, do so in moderation.
    • If your doctor gives you blood pressure medicine, take it the way the doctor tells you.
    High blood cholesterol
    Cholesterol in your arteries is like rust in a pipe. Low-density lipoprotein (LDL) is known as the "bad" cholesterol. Too much LDL cholesterol can clog your arteries, which increases the risk of heart disease and stroke. High-density lipoprotein (HDL) is known as the "good" cholesterol. HDL carries cholesterol away from your arteries.
    Check your total cholesterol number (mg/dL*)
    Desirable Less than 200
    Borderline High High 200—239
    High 240 or higher

     

    Check your LDL cholesterol number (mg/dL*)
    Desirable Less than 100
    Near Desirable/Above Desirable 100—129
    Borderline High 130—159
    High 160 or higher

    * Milligrams per deciliter

    The goal for LDL cholesterol is different for everyone. Your doctor can help you set your LDL goal.

    HDL levels of 60 mg/dL or higher help lower your risk for heart disease. HDL levels below 40 mg/dL are a major risk factor for heart disease.

    Check your triglyceride level (mg/dL):
    A normal triglyceride level is below 150.

    • Get a blood test called a lipid profile at your doctor's office. This test measures all your cholesterol levels (total, LDL, and HDL) and triglycerides.
    • Get your blood cholesterol levels checked every 5 years if you are age 20 or older.
    • Learn what your cholesterol numbers mean. If they are high, ask your doctor how you can lower them.
    • Choose foods that are lower in saturated fat, trans fat, and cholesterol.
    • Aim for a healthy weight.
    • Be physically active.

    Take these other steps to control triglycerides:

    • Limit candy, sweets, regular soda, juice, and other beverages high in sugar.
    • Avoid smoking and alcohol. Smoking raises triglycerides and lowers HDL cholesterol. Excess alcohol also raises triglycerides.
    Overweight
    Overweight occurs when extra fat is stored in your body. It increases your risk of developing high blood pressure, high blood cholesterol, heart disease, stroke, and diabetes.

     

    Check your body mass index (BMI) and waist measure:
    Category BMI
    Normal 18.5—24.9
    Overweight 25—29.9
    Obese 30 or greater
    • A waist measurement of more than 35 inches for a woman and more than 40 inches for a man increases the risk of heart disease.
    • Get your BMI and waist measured every 2 years, or more often if your doctor recommends it.
    • Aim for a healthy weight. Try not to gain extra weight.
    • If you are overweight, try to lose weight slowly. Lose 1 to 2 pounds a week.
    • Eat smaller portions and be physically active for at least 60 minutes daily.
    Diabetes
    When the sugar in the blood is high, your body cannot use the food you eat for energy.
    • Diabetes is serious. You may not know you have it. It can lead to heart attacks, blindness, amputations, and kidney disease.
    • Nearly 1 out of every 8 adult African Americans has diabetes.
    • Being overweight is a major risk factor for diabetes.
    • Find out if you have diabetes.
    • Get your blood glucose (blood sugar) level checked at least every 3 years, beginning at the age of 45. You should be tested at a younger age and more often if you are at risk for diabetes.
    Physical Inactivity
    Being inactive can double your chances of heart disease and take away years from your life.
    • Adults should do at least 30 minutes of moderate physical activity on most days, preferably daily.
    • Some adults need up to 60 minutes of moderate (medium-level) to vigorous (high-level) activity on most days to prevent unhealthy weight gain.
    • Adults who used to be overweight need 60 to 90 minutes of moderate physical activity every day to avoid regaining weight.
    • Children and adolescents need at least 60 minutes of moderate to vigorous physical activity on most days.
    • Stay active. You can build up to 60 minutes of exercise each day by being active for 20 minutes three times a day.
    • Try walking, dancing, or playing soccer.
    Smoking
    You put your health and your family's health at risk when you smoke.
    • Cigarette smoking is addictive. It harms your heart and lungs. It can raise your blood pressure and blood cholesterol and those of others around you.
    • Stop smoking now, or cut back gradually.
    • If you can't quit the first time, keep trying.
    • If you don't smoke, don't start.
  2. Family Health History Activity
    • Say:
      Looking at your family's health history can give you information about your own health and habits. Let's begin by looking at an example of a family health history.
    • Give each group member the "Harris Family Health History" handout.
    • Say:
      Earlier, we met the members of the Harris family. Their family health history shows health conditions that family members have in common.
    • Show picture card 1.1 of the Harris family while you review the handout. Ask a volunteer to read the health conditions of the Harris family members aloud.
    • Ask:
      • What can we learn about the Harris family by looking at their family health history?
      • Is there anything the family needs to be concerned about? If so, what?
        Note: Allow 2 or 3 minutes for group members to respond.
    • Add these answers if they are not mentioned:
      • The Harris family has a history of high blood pressure.
      • Darnell should see a health care provider to get screened for heart disease and its risk factors.
      • Several members of the Harris family smoke cigarettes and need to take action now to quit.
    • Say:
      Knowing your own family health history will help you take action to prevent and control your risk for heart disease and stroke.
    • Say:
      If you do not have living relatives or are adopted, it is important to learn your own risk factors for heart disease and live a heart healthy lifestyle.
    • Give each group member the "My Family Health History" handout.
    • Say:
      Please take the "My Family Health History" handout with you, and fill it out at home. It will be important to get your family involved. They may have information that will help you to know more about your risk for heart disease or stroke.
      Note: As you give the instructions that appear below, point to the specific area of the handout.
    • Say:
      Let's talk about how to fill out the "My Family Health History" handout.
      • For each family member, fill in his or her name, age, and health conditions—such as high blood pressure, high blood cholesterol, diabetes, heart attack, and stroke.
      • For any family member who has passed away, write down the cause of death and his or her age at the time of death.
      • As you move down your family health history, you will complete the health information for yourself, your spouse or partner, and your children.
    • Ask:
      How will you find out about the health history of your family?
      Note: Allow 2 or 3 minutes for group members to respond.
    • Add these answers if they are not mentioned:
      • You can ask your parents, brothers, and sisters whether they have risk factors for heart disease.
      • If your parents or siblings are no longer living, you can discuss what you know about their health history with other members of your family.
      • You can ask your adult children about their heart health. Also, you can review your young children's health records or speak with their health care provider on your next visit
    • Say:
      Some family members may feel embarrassed or uncomfortable sharing personal health information. Here are some tips to get the conversation going:
      • Share the handout with your family, and ask them to help you fill it out.
      • Share your own risk factors, and ask family members if they have the same risk factors or others.
      • Tell family members that you are taking a heart health course and want to share with them what you've learned about family health history.
    • Say:
      • In later sessions, I will ask for volunteers to share what they learned by completing the "My Family Health History" handout.
    • (Optional) Say:
      • Those of you who complete your family health history before the end of this course will receive a special prize!
    • Note: If you choose to, you can provide a prize to participants who finish their family health history.

Review of Today's Key Points

  • Ask:
    What are the risk factors for heart disease that we can prevent or control?
  • Add these answers if they are not mentioned:
    • Overweight
    • Physical inactivity
    • High blood pressure
    • High blood cholesterol
    • Diabetes
    • Smoking
  • Say:
    Although you cannot control your family health history, knowing your family risk factors can help you better understand your own risk and the actions you and your family can take to reduce your risk of heart disease.
  • Say:
    It can be hard to change old unhealthy habits and learn new healthy ones. As Rev. Jesse Jackson said, "If my mind can conceive it, and my heart can believe it, I know I can achieve it."
  • Say:
    This course will teach you what you need to know and how to make these changes slowly. Seeing you make healthy changes may make others want to make these changes, too.

Closing

  • Ask:
    Do you have any questions about the project?
  • Note: Give group members a moment to respond.
  • (Optional) Ask:
    How many of you want to go on a grocery store tour? During week 8 or 9, a registered dietitian can lead us through a grocery store and help us learn how to shop for our hearts.
  • Note: If enough group members are interested, call the grocery store in your area and set up a time for a tour.
  • Say:
    Thank you for coming today. What did you think of today's session?
  • Note: Allow a moment for group members to respond.
  • Say:
    In the next session, we are going to discuss the warning signs of a heart attack.
  • Note: Think about today's session. What worked and what didn't? Has the session helped you learn about your risk for heart disease?

Handouts

Introducing the Harris Family of the "With Every Heartbeat Is Life" Manual

An African American Family's Triumph

This manual tells the story of how the Harris family and friends have come together to triumph over heart disease and live heart healthy. They know from experience the toll that heart disease can have on families. They support and encourage each other to overcome challenges and learn new ways to live
heart healthy.

Ms. Diane Harris (Grandma Harris) is determined to be there for her family. Her resolve and spirit to improve her family's heart health is a beacon of light that the family follows.

The Harris family and friends show you how you can achieve a heart healthy lifestyle, too. They provide practical steps you can take in your own life and home situations to improve your heart health and feel better overall. Let's learn from their examples!

By choosing a heart healthy lifestyle, you can embrace the best that life has to offer—for yourself, your family, and future generations.



Are You at Risk for Heart Disease?

Name: ____________________

Risk factors are traits or habits that make a person more likely to develop heart disease. Read this list of risk factors for heart disease. Check the ones you have.

Heart disease risk factors you can do something about:

Check the ones that you have.

_____ Overweight
_____ Not sure

_____ High blood pressure
_____ Not sure

_____ High blood cholesterol
_____ Not sure

_____ Diabetes
_____ Not sure

_____ Physical inactivity

_____ Cigarette smoking

Heart disease risk factors you cannot control:

Check the ones that you have.

_____ Age (45 years or older for men and 55 years or older for women)

_____ Family history—

  • Father or brother with heart disease before age 55
  • Mother or sister with heart disease before age 65

The more risk factors you have checked, the greater your risk for heart disease. Talk to your doctor about your risk.



Harris Family Health History

Name: Ms. Diane
Age: 63
Relationship: Mother
Health Conditions: Diabetes, high blood pressure
Cause of Death (if applicable):
Age at Death:

Name: Tina
Age: 37
Relationship: Self
Health Conditions: Prediabetes, prehypertension, overweight
Cause of Death (if applicable):
Age at Death:

Name: Miles
Age: 8
Relationship: Son
Health Conditions:
Cause of Death (if applicable):
Age at Death:

Name: Bill
Age: Deceased
Relationship: Father
Health Conditions: High blood pressure, smoked cigarettes
Cause of Death (if applicable): Heart Attack
Age at Death: 55

Name: Darnell
Age: 27
Relationship: Brother
Health Conditions: High blood pressure, smoked cigarettes
Cause of Death (if applicable):
Age at Death:

Name: Imani
Age: 10
Relationship: Daughter
Health Conditions: Overweight
Cause of Death (if applicable):
Age at Death:

Name: Harold
Age: 65
Relationship: Uncle
Health Conditions: Diabetes, high blood pressure
Cause of Death (if applicable):
Age at Death:

Name: Pam
Age: 40
Relationship: Sister
Health Conditions: Overweight, high blood pressure, heart attack
Cause of Death (if applicable):
Age at Death:

Name: Elijah
Age: 13
Relationship: Son
Health Conditions:
Cause of Death (if applicable):
Age at Death:

Name: Faith
Age: 56
Relationship: Aunt
Health Conditions: Smoked cigarettes
Cause of Death (if applicable):
Age at Death:

Name: Ronnie
Age: 57
Relationship: Uncle
Health Conditions: High blood pressure
Cause of Death (if applicable):
Age at Death:

Name: Jamar
Age: 10
Relationship: Nephew
Health Conditions:
Cause of Death (if applicable):
Age at Death:



My Family Health History

Fill in the following information for each family member:

  • Name
  • Age
  • Relationship to you
  • Health conditions (examples: high blood pressure, high blood cholesterol, diabetes, smoking, overweight, heart attack, and stroke)
  • Cause of death and age at death (if a family member has passed away)

Name: ______________________________

Age: __________

Relationship: ______________________________

Health Conditions: ______________________________

Cause of Death (if applicable): ______________________________

Age at Death: __________


Name: ______________________________

Age: __________

Relationship: ______________________________

Health Conditions: ______________________________

Cause of Death (if applicable): ______________________________

Age at Death: __________


Name: ______________________________

Age: __________

Relationship: ______________________________

Health Conditions: ______________________________

Cause of Death (if applicable): ______________________________

Age at Death: __________


Name: ______________________________

Age: __________

Relationship: ______________________________

Health Conditions: ______________________________

Cause of Death (if applicable): ______________________________

Age at Death: __________


Name: ______________________________

Age: __________

Relationship: ______________________________

Health Conditions: ______________________________

Cause of Death (if applicable): ______________________________

Age at Death: __________


Name: ______________________________

Age: __________

Relationship: ______________________________

Health Conditions: ______________________________

Cause of Death (if applicable): ______________________________

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Name: ______________________________

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Relationship: ______________________________

Health Conditions: ______________________________

Cause of Death (if applicable): ______________________________

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Health Conditions: ______________________________

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Name: ______________________________

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Name: ______________________________

Age: __________

Relationship: ______________________________

Health Conditions: ______________________________

Cause of Death (if applicable): ______________________________

Age at Death: __________


Name: ______________________________

Age: __________

Relationship: ______________________________

Health Conditions: ______________________________

Cause of Death (if applicable): ______________________________

Age at Death: __________


Name: ______________________________

Age: __________

Relationship: ______________________________

Health Conditions: ______________________________

Cause of Death (if applicable): ______________________________

Age at Death: __________


Name: ______________________________

Age: __________

Relationship: ______________________________

Health Conditions: ______________________________

Cause of Death (if applicable): ______________________________

Age at Death: __________


Go To INTRODUCTION Go To SESSION 2

Last Updated December 2010

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