ANAMNESIS FORMAT:
I.
FAMILY ANCESTRY (Parents, Grandparents and Great Grandparents – if available)
II.
FAMILY COMPOSITION
a.
What can you say about your father, mother and siblings)
b.
Personal profile of each family member (Full name, Age, Birth date, Birth place, Occupation,
Educational Profile, Religion)
c.
Family Genogram (include heredofamilial diseases)
III.
FAMILY RELATIONSHIPS
a.
Roles of each family member
b.
Family and Home Responsibilities
c.
Family Ties
d.
Lines of Communication among members
e.
Means of Discipline
f.
Means of Relaxation and Recreation
g.
What do you LIKE and HATE most with your father, mother and siblings?
h.
How does your family cope with problems, conflicts and disappointments?
i.
How do you celebrate good times and success?
IV.
PERSONAL HISTORY
A. Life Review (in table presentation) in relation to:
1. Erikson’s Psychosocial Stages of Development
2. Freud’s Psychosexual Theory
3. Piaget’s Cognitive Theory
B. Biographic/Demographic data
Name
Age
Sex
Status
Address
Religion
Occupation
C. Name and meaning of birth name
D. Birth date and Time
E. Method of Delivery
F. Birthplace
G. Legitimacy as a Child
H. Parent’s Reaction
I. Was the pregnancy planned and wanted?
J. Who is your primary caregiver?
K. Immunization
L. Say something about yourself during the different life stages
a. Infancy
b. Toddlerhood
c. Preschool
d. Grade School
e. High School
f. College
V. Dreams, Ambition and Goals
A. Personal plans and goals
B. Social Ideals
C. Career Plans and Goals
D. Marriage Ideals and Plans
1. What is the meaning of ideal marriage for you?
2. What is your ideal age for marriage?
3. Who/What is your ideal partner?
4. What is your ideal family and home?
VI. Hero worship/Fantasies/Obsession/Pre-occupations/Nightmares
VII. Life Philosophy
VIII. Religion and Religious Views
IX. Traits
X. Summary and Conclusion
XI. Letter to self
XII. Letter to Parents