Writing Your History: an example

Here is an example of a personal history such as I've asked you to create.  Note that it's basically just one paragraph after another, because that format will go easily into my medical record program.   

Joan Jones' History  (fictional patient, fictional story, of course)

1. Main symptom: depression

I always seem to have a been "different" person.  There is no clear starting place, but depression was clearly present by the time I was in about 8th grade.  My parents divorced about a year before that, but I don't remember being very directly upset.  It sort of seemed like a good idea in some ways at the time.  But I really missed my dad after a few months. 

Since then, I've had phases of pretty severe depression off and on.  When I was 17, I thought pretty seriously about suicide, but never told anyone.  After my own divorce at age 27, I had a really severe depression and ended up in psychotherapy, which helped (below). 

The main problem now is my energy and motivation.  I'm really having trouble at work because of this.  I used to be the reliable person, but now, I just don't seem to care much about whether something gets done right, or not.  That's really not like me.  I also seem to get angry very easily, particularly at my husband, but it could be anybody, like my boss or even someone on the freeway.  

One of the reasons I need help now it that both my boss and my husband have complained about my behavior, the boss just recently, and my husband for months now.  They've been urging me to get some help.  Fortunately they've both been pretty understanding, but their patience seems to be wearing thinner.  

The other problem I'm having now is sleep:  I can fall asleep okay, but I wake up about 3-4 hours later and often can't get back to sleep at all.  Sometimes I can fall back to sleep but then I seem to wake up every hour for the rest of the night.  I don't feel rested at all when I wake up.  This started about a year ago and has been getting worse since.  It's been really bad lately, more nights than not.  I feel like I'm going crazy for lack of sleep.  

2. Past psych' treatments

I saw a therapist in Milwaukee, WI for about a year at age 27 after my divorce.  He was really helpful, but I don't know what "type" of therapy it was.  I saw him for about a year.  I tried it again recently in Corvallis but the therapist (James Brown) just didn't seem right for me.  

Recently my primary care doctor, Janet Doe, put me on Lexapro.  I'm still taking 10 mg now.  When the dose went to 20 mg I felt really weird so she suggested turning it down.  It seems to have improved my mood overall:  I'm less depressed than I was, but I think I might be a bit more anxious.  And it really messed up my sex life, which has now hit about zero. 

3. Past Medical History

I had my gall bladder removed at age 41.    I have pretty bad heartburn off and on and take prilosec for that when it's bad.  That helps some.  

My menstrual cycles are regular.  I'm sexually active, or was before the Lexapro anyway.  We use condoms.  

Lexapro 10 mg
Prilosec 20 mg
Ibuprofen for muscle aches -- about twice a week
Fish oil for mood and cholesterol: the Kirkland brand, 4 pills daily

My last blood test was more than a year ago. I was told everything was fine.  

4. Alcohol and Substance Use

I drink about 3 glasses of wine per week.  I used to drink as much as  bottle a day for a while, just after college, but stopped that on my own when a friend suggested I was drinking too much.  I don't like marijuana, it makes me feel weird, haven't done that for years.  Never tried anything else. 

5. Family History

My mother had depression and was on antidepressants for years.  I don't know all of them but I remember Prozac, that made her act really weird and was stopped after only a week.  She never has had a really great response to all the things they've tried.  

My dad got drunk a lot but now he has given it up entirely.  There are a lot of people on his side of the family with alcohol problems.  

My sister seems fine.  My brother gets pretty moody.  Sometimes he's hard to be around.  He gets really negative about things, can only see that bad part of anything.  I've always thought he should get some help for this. 

My mother's mother was also depressed, but that wasn't really talked about.  My mom mentioned it once.  That's all I know about her.  I think my sister's son might have ADHD, that was mentioned once also. 

6. Social History

When I was growing up, discipline was pretty harsh.  Dad yelled a lot and he would hit us when he was drunk; that was nearly weekly for a few years when I was in early grade school.  My mom didn't try to protect us, she seemed to have given up at that point.  

I experienced sexual abuse several times as I grew up.  I'd rather just explain it than try to write it down. 

I'm not being hit now.  My husband sometimes yells and sometimes when he does, I feel like I'm sort of flipping out.  Sometimes not though, I don't get it. 

I live with my husband and our two kids.  We both work.  Neither of us is making what we're worth, of course (who is?).

My emergency contact person is my husband, Rick Jones.  His cell phone is 444.444.4444. 

7. Reaching me
Address: 123 Straight St, Corvallis, Oregon 97330
Date of birth: 8/12/48
Telephone Number: 555.555.5555, where it's okay to leave a message (my work number; no one else listens to my voice mail). My cell phone number is 666-666-6666.