EMMAUS INSTITUTE

PERSONAL INVENTORY
INSTRUCTIONS: This confidential information form is for the use of your counselor. Complete it as
carefully as you can. If both husband and wife are coming for counseling, each should fill out a form. Be
sure to complete both sides.
IDENTIFICATION DATA
Your Name: _____________________________ Address: _______________________________________
City: ___________________ State: ______ Zip Code: ________ Home Phone: ______________________
Occupation: _________________________________________ Business Phone: _____________________
SEX: M F Birth Date: ______________ Age: _______ Height: _______ Nationality: ________________
Marital Status: (Please Check Where Appropriate)
Single: ___ Going Steady: ___ Engaged: ___ Separated: ___ Married: ___ Divorced: ___ Widowed: ___
Education (Please Circle Last Year Completed)
Grade School: 1 2 3 4 5 6 7 8 High School: 9 10 11 12 College: 1 2 3 4 5 6+
Other Training (List Type & Years): _________________________________________________________
Military History (Please Check): None: ___ List Branch of Service: ________________________________
Referred Here By: _______________________ Address: ________________________________________
HEALTH INFORMATION
Rate Your Physical Health (Check) Very Good: ___ Good: ___ Average: ___ Declining: ___
Your Approximate Weight: ________ lbs. Weight Changes Recently: Lost _____ Gained: _____
List all important present or past illnesses, or injuries causing handicap(s):
_______________________________________________________________________________________
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Date of Last Medical Exam: ________________ Report: _________________________________________
Your Physician: _________________________ Address: ________________________________________
Are You Presently Taking Medication: Yes: ___ No: ___ What?: _________________________________
Have you ever been treated or seen by a psychiatrist?

Yes: ___ No: ___

Have you ever ad a nervous breakdown or severe emotional upset?: Yes: ___ No: ___
RELIGIOUS BACKGROUND
Denominational Preference: _________________________ Church Attendance per Month: 0 1 2 3 4 5+
Church attend in Childhood: _______________________________________ Baptized?: Yes: ___ No: ___
Religious Background of Spouse (if married): __________________________________________________
Explain any recent changes in your religious life (if any): _________________________________________
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Explain any past remarkable religious experiences: ______________________________________________
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