Personal History
This is an account of the patient's life from conception up to the present. It should incorporate what they know of the circumstance of their birth, their earliest memories, development, achievements and interactions and life story in outline. This can be the hardest section to complete in a history as a lot of personal questions may be asked having a good rapport really counts here.
Its good to begin by telling the patient that you want to find out about their life and what it was like growing up for them. It makes it easier to split this up into manageable sections. You can do this by ‘life stage' under each stage there is information which should be obtained.
Birth / Infancy
- Birth timing and complications
'Were you told if you smiled, talked, walked, ate when you should have?'
'Were you ever told of complications at your birth?'
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Childhood
- Family relationships in upbringing
Nursery and early schooling
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Socialising and befriending
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Academic and sporting abilities
'Tell me a bit about you background, where you grew up and what it was like?'
'How many siblings do you have, how did you get on with them?'
'What did your parent do for a living?'
'What happened when you disobeyed them?'
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Adolescence
- School life and academic achievements
- Pubertal development (physically and psychological)
- Peer relationships (including sexual)
- Have you experimented with Alcohol, drugs, antisocial behaviour
'Did you have a best friend?'
'When did you begin having an interest in the opposite sex?'
'How you were at school work, what did you like?'
'Did you ever drink, take drugs or get into trouble with the police?'
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Adulthood
- Martial and sexual history (list of past relationships, children, bereavements)
'How has you marriage (relationship) been?'
'Why did you choose this career?'
'Do you have any children? What are they like?'
'Do you like your work?'
'How do you get on with your colleges?'
'Who would you turn to in times of hardship?'
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The personal history should come up to the point at which the patient is at now with their life. You should have gained important information about factors which may have predisposed, precipitated or maintained the condition this will be important in formulating the aetiology.
| Example. Miss. Andrews |
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'Miss. Andrews had a few complications when she was born. Her mother had a viral like illness during the pregnancy and the labour lasted two days. She recalled her mother crying when she recalled the birth saying "I remember the doctors telling me you had deteriorated"
"Mum told me I was never a quick learner" she found starting nursery difficult and recalls crying for hours and feeling very scared. She was always a reserved girl and found it difficult to start or have conversations with peers "I could have violent outbursts as well if pushed". She never excelled academically and her school reports where always poor. She left school at 15 having attained no qualifications and went to work in a local factory making buns. She was regarded at a hard worker but was sacked after 3 year as she began having difficulty with co workers "they hated me and talked about me behind my back, saying horrible things and plotting to kill me with a poisoned bun".
She has always got on well with her mother and still lives with her now, her father died 5 months before she was born. She had two older bothers who passed away when she was in secondary school (aged 14) "that's what put a spanner in the works for me at school" Her mother was brought up in a conservative catholic family and has attend church all her life this somewhat influenced Miss. Andrews.
She remained unemployed after the bun job as she found that her worsening anxiety stopped her getting past the interview of any job. She has recently given up looking for work and wants to get a "job working from home away from people... then I can look after mum as well"
She has lived in the same house all her life with her mother. She keeps in touch with a small network of family and friends, her great aunt Bertha calls in most weekends. She attends social evenings with her mum and aunt at the local women's institute which she is a longstanding member of. She has never had a sexual relationship and said "I don't seem to have ever had any sexual feelings" |
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