ANAMNESIS ( history taking from a patient )

1. 1. PASSPORT DETAILS

1.1. residence

1.2. name

1.3. surname

1.4. age

1.5. birth place

1.6. gender

2. 3. ANAMNESIS VITAE

2.1. immunisations

2.2. past reasons to visit hospital

2.3. patient occupation

2.4. unexpected deaths

2.5. marriage/divorce

2.6. allergies

2.6.1. rash

2.6.2. anaphylaxis

2.6.3. adverse reactions

2.7. obstetric

2.7.1. pregnancy

2.7.2. frequency

2.7.3. spontaneous/therapeutic abortion

2.7.4. full term delivery

2.8. sexual activity

2.8.1. STI

2.8.2. kids

2.8.3. birth control

2.8.4. virgin

2.8.5. number

2.8.6. type

2.8.7. frequency

2.9. social status

2.9.1. low income

2.9.2. bad relations

2.10. diseases suffered in past years

2.11. medication taken

3. 5. BAD HABITS

4. 2. ANAMNESIS MORBI ( history of present illness)

4.1. when

4.2. type

4.3. chief complaint

4.4. duration

4.4.1. how long

4.4.2. similarity to past issues

4.4.3. what was done last time

4.5. pace of illness

4.6. severity

4.6.1. scale of 1-10

4.6.2. affect activity level

4.6.3. felt anything similar

4.7. localisation

4.8. irradiation

4.8.1. symptoms in specific places

4.8.2. change in localisation

4.9. night time ( normally inflammation)

4.10. character of pain

4.10.1. division of pain is sharp/ dull/ stabbing/ heavy/ ache / pressured

4.10.2. constant/ intermittent

4.10.3. movement of pain ( motor/ muscular issues)

4.11. relieving / provoking factors

5. 4. ANAMNESIS FAMILIAE

5.1. lifestyle

5.2. addictions

5.3. unusual illness among relatives ( genetics)

5.4. heritable diseases

5.4.1. age of onset

5.4.2. primary/ secondary relatives in coronary heart disease/ diabetes mellitus

6. 6. REVIEW OF SYSTEMS