个人史是记录个人的生活史、生活习惯、职业与工作情况；嗜好及其他情况；女性还应记录婚育情况。个人史多用陈述句表述，有时也用省略句。句中常用一般现在时般过去时和过去完成时。例如： 

 

个人史：患者与男友同居。患者无工作，无子女。承认过去20年来每天吸烟一包，也喝酒。称每天只喝40盎司啤酒。显然她曾数次试图戒酒但未成功。病人否认经静脉注射毒品史。 

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.

 

常用词语和表达方式：

有…的习惯：have a habit of ...

有长期吸烟史：have a long history of smoking 

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

…的吸烟者：a heavy smoker of no less than a pack a day； a two-pack-a-day smoker

承认（喝酒，吸烟等）：admitted to ... (drinking, smoking, etc.)

喜欢饮酒：like / enjoy / have a taste of. drinking 

偶尔适量饮酒：drink only occasionally and in moderation 

纵酒，嗜酒：be indulged in drinking 

酗酒：drink often and to excess, alcohol abuse 

慢性酒精中毒：chronic alcoholism

不嗜烟酒：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

喜欢吃零食：have a habit of eating between meals

喜欢吃热（冷、咸、甜、辣）的食物...： like / prefer hot (cold, salty, sweet, hot / pungent) food

喜欢喝浓茶(咖啡）:prefer heavy tea / strong coffee 

喜欢早起：have the habit of getting up early 

喜欢晚睡 / 熬夜：tend to go to bed / stay up late 

无特别兴趣与爱好：have no special interests or hobbies 

喜欢运动：be fond of sports

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

曾做过…工作：worked as...

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

不能胜任强负荷工作：be incapable of heavy workload

未婚：single, unmarried

未孕妇：nulligravida

初产妇：primipara

经产妇：multipara, pluripara

怀孕3次，生产两次:gravida iii，para ii

结婚…年，一直未孕 i have been married for ,. years without conception 

无流产或早产史：have no history of abortion or premature births 

因避孕失败而怀孕：be / become pregnant through inadequate contraccption

不能生育：be unable to have children 

无子女：have no children

实行节育，计划生育：practice birth control / family planning