Past, personal and family history

Previous illness and recovery

Document previous psychiatric and medical episodes, their timing, the symptoms described, treatment received and the level of functioning between episodes. Distinguish diagnoses recorded in earlier records from diagnoses recalled by a patient or relative. A previous label is part of the history, rather than an automatic conclusion about the current presentation.

Treatment history includes what helped, what caused difficulty and why treatment stopped. Where possible, connect these details with the episode timeline. Avoid equating the absence of hospital admission with the absence of significant illness.

Personal history as a life course

Explore development, education, work, relationships, living circumstances and important transitions. Select detail that helps explain the current difficulty and the person’s usual functioning. Background strengths, interests and ways of handling adversity deserve space alongside stress and loss.

Describe premorbid patterns through examples rather than unsupported personality labels. Ask how the person related to others, approached responsibilities and used leisure time before the illness. The aim is an individual picture, not a character judgement.

Family illness and family context

Family history covers both reported illness and the relationships in which the person lives. Record the source of information about a relative’s condition and the degree of uncertainty. Describe practical support, conflict and changes in the household without assuming that family history determines an outcome.

A genogram can organize relationships and major events for discussion. In teaching, use an original synthetic family; a real family history belongs in the authorized clinical record, not in a public website.

For your next supervision discussion

Choose a background detail from a synthetic case and explain why it matters to the current question. Then identify a strength or support that would be missed by recording vulnerabilities alone.