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