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PERSONAL DATA INVENTORY
IDENTIFICATION DATA:
Name ___________________________________ Phone_________________Cell_________________
Address __________________________________________________________________________________
E-Mail_____________________________________________
Age ____________ Date of Birth ________________________ Sex _______________________________
Occupation ______________________________________ Business Phone ________________________
Education (last year completed) _______________________________ Grade _____________________
Marital Status Single _____ Going steady _____ Engaged _____ Married _____
Remarried _____ Separated _____ Divorced _____ Widowed_____
Church attending_____________________________________ Phone ______________________________
Church address ___________________________________________________________________________
Pastor’s name ___________________________________________ Are you a member _____________
Does your counselor have permission to talk to your Pastor about your counseling issues?
Yes_____ No______ If yes, please sign here__________________________________________________
Referred here by __________________________________________ Address _______________________
COUNSELING DATA:
What is your problem: ______________________________________________________________________
What have you done about it: _______________________________________________________________
How can we help: ___________________________________________________________________________
HEALTH INFORMATION:
Rate your health: Very good_____ Good_____ Average_____ Declining _____ Other_____
If “other” explain __________________________________________________________________________
Recent weight changes: None _____ Lost _____ Gained _____
List all present and past illnesses, injuries, or handicaps ____________________________________
____________________________________________________________________________________________
Date of last medical examination __________________________ Report _________________________
Physician’s name __________________________________________________________________________
Address ______________________________________________ Phone_____________________________
List previous surgeries (those requiring anesthesia) _________________________________________
____________________________________________________________________________________________
List all prescriptions and over the counter medications (including diet pills, laxatives, birth
control pills, cold and allergy medications, aspirin, etc.) you are presently taking ___________
____________________________________________________________________________________________
Have you abused street drugs or alcohol ________________ To what extent ___________________
What is your average daily caffeine consumption (including coffee, tea, chocolate, stimulants,
and caffeinated soft drinks) ________________________________________________________________
Do you have problems sleeping _______ Any recent changes _________ Is your sleep restful____
Have you had any of the following physical problems (please check one):
Stroke_____ Brain tumor_____ Liver problems_____
Cancer_____ Lung problems_____ Kidney problems_____Anemia_____Congestive heart failure_____Heart problems_____
Allergies_____ Hypoglycemia_____ Palpitations_____
Asthma_____ Vitamin deficiency_____ Blackouts_____
Neurological Problems_____ Head injury/concussion_____ Seizures_____
Anorexia_____ Bulimia_____ Diabetes_____
Emphysema_____ Multiple Sclerosis_____ Deficiency disease_____
Endocrine problems_____ Sexually Transmitted disease_____ Genital problems_____
Parkinson’s disease_____ Mitral valve prolapse_____ Other_____
Do you have any of the following symptoms (please check):
Fever_____ Visual disturbances_____ Menstrual irregularities_____
Depression_____ Double vision_____ Heat/cold intolerance_____
Rashes_____ Blurry vision_____ Nausea/vomiting_____
Insomnia_____ Food cravings_____ Recent weight change_____
Fatigue_____ Feel tense_____ Poor bowel/bladder control_____
Deja vu_____ No appetite_____ Problems with speech_____
Weakness_____ Memory problems_____ Unusual hair loss_____
Dizziness_____ Fainting spells_____ Personality changes_____
Tremors_____ Incontinence_____ Episodic disorientation_____
Pneumonia_____ Constant hunger_____ Changes in consciousness_____
Impotence_____ Incoordination_____ Changes in sexual desire_____
Nightmares_____ Sensory distortions_____ Unusual physical changes_____
Headaches_____ Hallucinations (in any of the five senses) ___________
Other_______________________________________________________________________________
Have you ever had a severe emotional upset ____________ If yes explain ______________________
PERSONALITY INFORMATION:
Have you ever had counseling or psychotherapy before ___________ If yes list counselor or
therapist and dates ________________________________________________________________________
What was the outcome _____________________________________________________________________
Have you ever felt people were watching you __________ Do faces seem distorted ____________
Do you have difficulty distinguishing people’s faces ________ Do colors seem too bright _______
Too dull ___________ Are you sometimes unable to judge distance ______________
Is your hearing exceptionally good ______________
Have there been any deaths in your family during the last year ___________
Who ___________________________________ When ____________________________________________
Have you ever been arrested ____________ State circumstances ______________________________
What are your hobbies _________________________________ Activities _________________________
How is most of your time occupied _________________________________________________________
Check any of the following words that best describe you now:
Active___Ambitious___Calm___Self-confident___Persistent___
Hardworking___Impatient___Impulsive___Quiet___Often-blue___Nervous___Moody___Excitable___Shy___Imaginative___
Serious___Easy-going___ Good-natured___ Introvert___ Extrovert___Likeable___ Hard-boiled___ Submissive___
Self-conscious___Lonely___Sensitive____ Leader_____
Other: ______________________________________________
MARRIAGE AND FAMILY INFORMATION:
Name of spouse _____________________________________ Age ___________________________________
Address _______________________________________Phone ________________Cell___________________
Occupation ______________________________ Business Phone __________________________________
Education (in years) _____________________ Religion __________________________________________
Is spouse willing to come for counseling ______________ Have you ever been separated_________
If yes when _______________________
Has either of you filed for divorce ______________________ If yes when ______________
Date of marriage ____________________ Your age when married ____________ Spouse _________
How long did you know your spouse before marriage _________ Length of steady dating with
Spouse __________ Length of engagement ___________
Give brief information about any previous marriages_________________________________________
If you were reared buy anyone other than your own parents please explain___________________
How many older brothers______ sisters________ do you have?
How many younger bothers______ sisters_______ do you have?
Children’s names
Ages
Sex
Living
Education
Marital Status
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