個(gè)人史是記錄個(gè)人的生活史、生活習(xí)慣、職業(yè)與工作情況；嗜好及其他情況；女性還應(yīng)記錄婚育情況。個(gè)人史多用陳述句表述，有時(shí)也用省略句。句中常用一般現(xiàn)在時(shí)般過去時(shí)和過去完成時(shí)。例如： 

 

個(gè)人史：患者與男友同居?；颊邿o工作，無子女。承認(rèn)過去20年來每天吸煙一包，也喝酒。稱每天只喝40盎司啤酒。顯然她曾數(shù)次試圖戒酒但未成功。病人否認(rèn)經(jīng)靜脈注射毒品史。 

SOCIAL HISTORY： The patient lives at home with her boyfriend. The patient does not work. She has no children. She admitted to tobacco use one pack per day for about 20 years. She admitted to alcohol. She only admitted to one 40 ounce beer a day. Apparently she had attempted to quit drinking several times but was unsuccessful. She denied IVDA.

 

常用詞語(yǔ)和表達(dá)方式：

有…的習(xí)慣：have a habit of ...

有長(zhǎng)期吸煙史：have a long history of smoking 

每日吸煙…：smoke (10 cigarettes, a pack, two packs . . . ) a day 

…的吸煙者：a heavy smoker of no less than a pack a day； a two-pack-a-day smoker

承認(rèn)（喝酒，吸煙等）：admitted to ... (drinking, smoking, etc.)

喜歡飲酒：like / enjoy / have a taste of. drinking 

偶爾適量飲酒：drink only occasionally and in moderation 

縱酒，嗜酒：be indulged in drinking 

酗酒：drink often and to excess, alcohol abuse 

慢性酒精中毒：chronic alcoholism

不嗜煙酒：have no habit of smoking and drinking (alcoholic beverages)； do not smoke and drink

不偏食：have no likes or dislikes in food

不挑食：be not particular about food

喜歡吃零食：have a habit of eating between meals

喜歡吃熱（冷、咸、甜、辣）的食物...： like / prefer hot (cold, salty, sweet, hot / pungent) food

喜歡喝濃茶(咖啡）:prefer heavy tea / strong coffee 

喜歡早起：have the habit of getting up early 

喜歡晚睡 / 熬夜：tend to go to bed / stay up late 

無特別興趣與愛好：have no special interests or hobbies 

喜歡運(yùn)動(dòng)：be fond of sports

從事…工作.work as... , be ... , be employed as... , serve as ...

曾做過…工作：worked as...

工作能力強(qiáng)（差，稍差）：working capacity is good (poor, slightly impaired...)

不能勝任強(qiáng)負(fù)荷工作：be incapable of heavy workload

未婚：single, unmarried

未孕婦：nulligravida

初產(chǎn)婦：primipara

經(jīng)產(chǎn)婦：multipara, pluripara

懷孕3次，生產(chǎn)兩次:gravida iii，para ii

結(jié)婚…年，一直未孕 i have been married for ,. years without conception 

無流產(chǎn)或早產(chǎn)史：have no history of abortion or premature births 

因避孕失敗而懷孕：be / become pregnant through inadequate contraccption

不能生育：be unable to have children 

無子女：have no children

實(shí)行節(jié)育，計(jì)劃生育：practice birth control / family planning