Personal History

CHECK-LIST:

  • Birth and childhood
  • Education
  • Employment
  • Relationships
  • Psycho-sexual history
  • Family history

GUIDANCE:

The aim for this section is to try to gain a chronological history from birth to present.  It can be a lengthy area and is likely to be one that can be built upon at subsequent reviews.  Using subheadings can be useful.  Information collected should be both factual and qualitative to build a full picture of the patient’s life.

Birth and childhood:

  • Place of birth, gestation at delivery, any obstetric complications.
  • Developmental milestones. Any behavioural or emotional problems in childhood.
  • Where did they grow up, who did they grow up with, what was it like? What was adolescence like?
  • What were relationships like within the family? Which family members were most important growing up?
  • Any significant life events. Any bereavements or separations.
  • Any history of abuse – physical, emotional, sexual or neglect.

Education:

  • Schooling (primary and secondary) and details of any higher education – start and end of education. Consider type of schools – mainstream or specialist, dates. Any learning disability?  If left education before completing course or qualifications, why was this?
  • Qualifications gained. How did they feel they achieved, academic performance, sport, music etc.  Aspirations, did they feel they met their potential, if not why not?
  • Any difficulties in school, any exclusions, truancy or behavioural problems. Any history of bullying?
  • Did they enjoy school? How did they get on socially?  Relationships with peers, friends and teachers.

Employment:

  • Current employment, previous jobs and periods of unemployment.
  • For each job consider – type of work, duration and dates, job satisfaction, reasons for change (e.g. sacking, redundancy, did not enjoy), relationships with colleagues, bosses, pay and promotions. Is the type of job consistent with level of educational attainment?
  • If unemployed, any hopes for future work? How do they fill their time?

Relationships:

  • Current relationships and previous.
  • For each relationship consider – name and age of partner, duration, quality. Why did the relationship end, difficulties within the relationship, character traits of partner, occupation of partner, any on-going contact, any children?  Any violence within the relationship?
  • If multiple relationships consider summarising with first partner, other long term relationships (>6m), longest relationship.

Psychosexual history:

  • This may be difficult to elicit and may be excluded if judged to be inappropriate or not relevant.
  • Onset of puberty and menarche if female.
  • Sexual orientation.
  • First sexual encounter.
  • Current sexual relationships (practice of safe sex, contraception). If female, any pregnancies or terminations?
  • Any sexual difficulties or abnormal sexual practices.

Family history:

  • Family tree.
  • Names, ages, location, occupation and current contact – particularly of first degree relatives.
  • Any children? Names, dates of birth, schools, location and current contact with all children.  Any dependent children? (Document this in Central Index safeguarding section)
  • Personality of, and relationship quality with, key family members.
  • Significant health problems (mental and physical health, substance abuse) in family (particularly first and second degree relatives). Are there any familial illnesses?
  • Family history of suicide.