Guide for History
Making or Anamnesis
Prepared by :
Jesusa C. Gabule RN,MN
Learning Outcome
1. Understand the important concepts in
performing anamnesis.
2. Remember the specific guide in making
anamnesis and its proper documentation
3. Apply the therapeutic communication in
performing anamnesis.
Anamnesis
from a Greek word
meaning "remembering.“
"reminiscence."
3 Components
in Anamnesis
1. Informant
2. Family
History
3. Personality
History
1. INFORMANT
INFORMANT
Mother
Father
INFORMANT
Siblings
Grandparents
INFORMANT
Best
Friend
Neighbors
Boy Friend
or Girl Friend
Nanny
Direct Boss
Teachers
Co-worker
INFORMANT
1. Name
2. Address
3. Relationship to patient
4. Length of time known to patient
5. Apparent understanding of present
illness of the patient
6. Other characteristics and attitude of the
informant.
2. FAMILY HISTORY
A. Maternal
and Paternal
Grand
Lineage
2. FAMILY HISTORY
A. Maternal and Paternal Grand Lineage
- History of nervous
and mental disease
- Alcoholism
- Delinquency
- Drug addiction
- Suicide
-
Heredity
Dependency
Chronic
unemployment
and other traits of
inefficiency.
2. FAMILY HISTORY
B. Father
✓ What kind of a MAN
is the father ?
✓ What is his Social &
Financial Status.
✓ What are his habits
both Natural &
Acquired
2. FAMILY HISTORY
B. Mother
✓ What kind of a WOMAN
is the Mother ?
✓ Is she WORKING ?
✓ Method of disciplining
the children.
✓ How is her relationship
towards her HUSBAND
& other member of the
household.
2. FAMILY HISTORY
B. Siblings
✓ Number of Brother
& Sisters.
✓ Relationship of
Siblings toward
each other & to the
members of the
household.
✓ Personality Traits
3. Personality History
A. Prenatal
✓ Attitude of the Mother
towards pregnancy.
✓ Describe the health of
the mother.
3. Personality History
B. Infancy & Childhood
Characteristics
✓ Breast & Bottle feed
- Describe the feeding habit
- Cuddled during feeding.
✓ Was left under the care of the
“yaya”
✓ Age of teething, talking and
walking.
3. Personality History
B. Infancy & Childhood
Characteristics
✓ WHEN & HOW the child
is TOILET trained.
3. Personality History
C. Psychosexual History
3. Personality History
C. Psychosexual History
✓ Age of sex awareness
✓ Masturbatory practices
observed
✓ Age of menstruation.
✓ Male: Age when
lowered in pitch.
✓ Age of Circumcision
3. Personality History
D. Play Life
✓ What type of game
he/she preferred ?
✓ Play with SAME or
OPPOSITE sex.
✓ Plays with OLDER or
YOUNGER.
✓ LEADER or FOLLOWER.
3. Personality History
E. School History
✓ Age entering school.
✓ Age leaving school.
✓ Grade Completed.
✓ Attitude towards
school.
✓ Relationship with
teacher.
✓ Attendance
✓ Interest in studies.
✓ Grades/ marks
obtained
3. Personality History
F. Religion & Social Ability
✓ Number of friends,
age, sex social levels.
✓ Social attitudes &
Characteristics.
✓ Degree of religious
interest &
involvement.
✓ Reaction towards
failure & success.
3. Personality History
G. Occupational History
✓ Present Occupation
✓ Kind of work undertakes
✓ Length of time in different
jobs.
✓ Reasons for changes of
jobs.
✓ Attitude toward work with
superior, subordinates &
Co-worker.
3. Personality History
H. Marital History
✓ Love Affairs and disappointments
✓ Circumstances of marriages
✓ Attitude to each other towards sex
relations
✓ Age of marriage
3. Personality History
H. Marital History
✓ Perverted or Overt sexual practice.
✓ Miscarriage / Abortion, Sterility.
✓ Birth control measures.
✓ Infidelity of either one.
✓ Reasons for divorce or separation.
✓ Age of Menopause
Onset of Present Illness
✓ What incident precipitated the patient’s
present condition.
✓ Describe the symptoms manifested by
the patient which prompted the
relatives to sought hospitalization.
✓ Who brought the patient to the hospital.