Something along these lines:
Dates
Name
Location
Description
Reason for leaving
So for example:
Dates: Fall-Winter 1971
Name: Carol
Location: University of Washington
Decription: Tall, sturdily-built blonde. Commodore of UW Yacht club. 20 years old.
Reason for Leaving: She dumped me over an argument about whether it was wise to push the boat away from the dock when all the sheets were frozen.