Life Enrichment Christian Counseling Center
Please fill out and forward to your counselor

 
 
 

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:_________________________________________________________________________________