Personal Data Inventory

Identification Data:

Name:

Address:

Phone:

Occupation:

Business Phone:

Sex:

Height:

Birth Date:

Age:

Marital Status

Education (last year completed):

Other training:

Referred here by:

Address:

Health Information:

Rate your health: Very Good Good Average Declining Other

Your approximate weight:

Weight changes recently: Lost Gained

List all important present or past illnesses or injuries or handicaps:

Date of last medical examination:

Report:

Your physician:

Address:

Are you presently taking medication?

What?

Have you used drugs for other than medical purposes?

What?

Have you ever had a severe emotional upset?

Explain:

Have you ever been arrested?

Are you willing to sign a release of information form so that your counselor may write for social, psychiatric or medical reports?

Have you recently suffered the loss of someone who was close to you?

Explain:

Have you recently suffered loss from serious social, business, or other reversals?

Explain:

Religious Background:

Denominational preference:

Member:

Church attendance per month (circle): 1 2 3 4 5 6 7 8 9 10+

Church attended in childhood?

Baptized?

Religious background of spouse (if married):

Do you consider yourself a religious person?

Do you believe in God?

Do you pray to God?

Are you saved?

How much do you read the Bible?

Do you have regular family devotions?

Explain recent changes in your religious life, if any:

Personality Information:

Have you ever had any psychotherapy or counseling before?

If yes, list counselor or therapists and approximate dates:

What was the outcome?

Circle any of the following words which best describe you now:

Active ambitious self-confident persistent nervous hardworking impatient impulsive moody often-blue excitable imaginative calm serious easy-going shy good natured introvert extrovert likeable leader quiet hard-boiled submissive lonely self-conscious sensitive other_________________

Have you ever felt people were watching you?

Do people’s faces ever seem distorted?

DO you ever have difficulty distinguishing faces?

Do colors ever seem too bright? Too dull?

Are you sometimes unable to judge distance?

Have you ever had hallucinations?

Are you afraid of being in a car?

Is your hearing exceptionally good?

Do you have problems sleeping?

Marriage and Family Information:

Name of spouse:

Phone:

Address:

Occupation:

Business Phone:

Your spouse’s age:

Education (in years):

Religion:

Is your spouse willing to come for counseling?

Have you ever been separated?

Date of marriage:

Your ages when married: Husband_________ Wife__________

How long did you know your spouse before marriage?

Length of steady dating with spouse:

Length of engagement:

Give brief information about any previous marriage:

Information about children: (Write “PM” if child is by a previous marriage.)

Name Age Sex Living(Y or N) Education Marital Status

If you were reared by anyone other than your own parents, briefly explain:

How many and what kind of siblings do you have?

Briefly Answer the Following Questions:

What is your problem?

What have you done about it?

What can I do? (What are your expectations in coming here?

As you see yourself, what kind of person are you? Describe yourself:

What, if anything, do you fear?

Is there any other information I should know?