Family, Personal and Healthy Inventory
I.
Family History & Relationships
 Religious History
o Would you describe your parents as religious? Describe:
______________________
___________________________________________________________________
o Have any of your parents, grandparents, or great-grandparents to your knowledge
ever been involved in any occult, cultic, or non-Christian religious practices? Please
describe: ___________________________________________________________
___________________________________________________________________
o Briefly describe your parents’ Christian experience (I.e. if they were believers, did
they profess and live their Christianity)?
___________________________________
___________________________________________________________________
o What is your religious affiliation?
________________________________________
o Are you currently involved in a church body? ______________________________
o Name of the church: __________________________________________________
o How would you describe your relationship with the Lord? ____________________
___________________________________________________________________
___________________________________________________________________
 Marital Status (parents)
o Are your parents presently married or divorced? Explain: _____________________

If divorced, how old were you when that occurred? _____________________
o Was your father clearly the head of the home or was there a role reversal (Ie. where
your mother was dominant)? Explain: ____________________________________
___________________________________________________________________
___________________________________________________________________
o How would you describe your father’s leadership in the home? ________________
___________________________________________________________________
o How did your father treat your mother? __________________________________
o How did your mother respond to him? ___________________________________
o Did your father treat women with respect? ________________________________
o Did you mother treat men with respect? __________________________________
o Did your parents provide guidance and helpful direction concerning the important
issues of life (Ie. moral choices, education, spiritual growth, relationships, sex, dating, church, work, career, health, finances, etc.)? ____________________________
___________________________________________________________________
___________________________________________________________________
o In what areas would you have liked them to give you more guidance? Explain: ____
___________________________________________________________________
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o How did you respond when family conflicts occurred? _______________________
___________________________________________________________________
o Who was the ‘disciplinarian’ in the home when growing up? And how did that
person discipline you? _________________________________________________
o Are you aware of any physical, emotional or sexual abuse in your family line (Ie. 34 generations)? Describe:
________________________________________________
___________________________________________________________________
___________________________________________________________________
o Is there a history of physical, emotional or sexual abuse in your past?
____________
___________________________________________________________________
o Was there ever an adulterous affair to your knowledge with your parents or
grandparents? Any incestuous relationships? _______________________________
___________________________________________________________________
o Are there any fearful, painful or traumatic experiences or events not mentioned here
that may be important? Explain: ____________________________________
___________________________________________________________________
 Sibling Data:
o Please identify sex and age of sibling(s) and place self in birth order:
_____________
___________________________________________________________________
___________________________________________________________________
o Please describe the emotional atmosphere in home while growing up. Include brief
description of relationship with parents and sibling(s):
________________________
___________________________________________________________________
___________________________________________________________________
o Who was your father’s favorite? _________________________________________
o Who was your mother’s favorite? ________________________________________
o What was your health like, from birth to age 10 (Ie. any illnesses, hospitalizations,
accidents)? __________________________________________________________
o What were your fears as a child? (Ie. any nightmares or night terrors?)
___________
___________________________________________________________________
o What are your earliest memories before age seven (name three)? _______________
___________________________________________________________________
___________________________________________________________________
o What was school like for you growing up?
_________________________________
o How would you describe your teen years? Name significant memories?
__________
___________________________________________________________________
___________________________________________________________________
o What was your spiritual environment growing up? __________________________
___________________________________________________________________
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 Marital Status (personal)
o Are you currently married? _____________ If yes, how long? _________________

Spouse’s Name: _________________________________________________

Spouse’s Occupation: _____________________________________________

Previous Marital History: __________________________________________
o In what areas are you and your spouse most compatible? _____________________
___________________________________________________________________
___________________________________________________________________
o Rate your level of communication with your spouse (1=Low; 10=High): _________

Explain: _______________________________________________________
o What does your spouse like about you? ___________________________________
___________________________________________________________________
o What does your spouse dislike about you? _________________________________
o What do you like about your spouse? _____________________________________
___________________________________________________________________
o What do you dislike about your spouse?
___________________________________
o What are the primary concerns in your marriage (from your perspective)? ________
___________________________________________________________________
___________________________________________________________________
o From your spouses perspective? _________________________________________
___________________________________________________________________
o Who is currently living in your household? ________________________________
 Relationship With Your Father
o Describe your relationship with your father during childhood: _________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
o Did he spend quality time with you? Why or why not and how did that make you
feel towards him? ____________________________________________________
___________________________________________________________________
o How did that make you feel about yourself?
________________________________
___________________________________________________________________
o How would you describe your father’s temperament and character? ____________
___________________________________________________________________
o How did your father show you affection? (Eg. Did he say, “I love you.”)?
_________
___________________________________________________________________
o How did your father give you praise or affirmation? _________________________
o What did your father criticize you or others for? ____________________________
o How did you handle it when he criticized you (Ie. did you shut down emotionally,
argue with him, make excuses, defend yourself, determine to try harder, give up)?
___________________________________________________________________
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o Summarize the most hurtful things he ever did or said to you: _________________
___________________________________________________________________
o How do you think this affected your perception of yourself?
___________________
___________________________________________________________________
o Has your relationship with your father changed in recent years? Explain: ________
___________________________________________________________________
 Relationship With Your Mother
o Describe your relationship with your mother during childhood: ________________
___________________________________________________________________
o Did she spend quality time with you? Why or why not and how did that make you
feel towards her? _____________________________________________________
o How did that make you feel about yourself?
________________________________
___________________________________________________________________
o How would you describe your mother’s temperament and character? ___________
___________________________________________________________________
o How did your mother show you affection? (E.g. Did she say, “I love you.”)?
______
___________________________________________________________________
o How did your mother give you praise or affirmation? ________________________
o What did your mother criticize you or others for? ___________________________
o How did you handle it when she criticized you (Ie. did you shut down emotionally,
argue with her, make excuses, defend yourself, determine to try harder, give up)?
___________________________________________________________________
o Summarize the most hurtful things she ever did or said to you: _________________
___________________________________________________________________
o How do you think this affected your perception of yourself?
___________________
___________________________________________________________________
o Has your relationship with your mother changed in recent years? ______________
___________________________________________________________________
II.
Health (General):
 Are there any addictive problems in your family history (alcohol, drugs, etc.)?
____________
__________________________________________________________________________
 Is there any history of mental illness? Please describe: _______________________________
__________________________________________________________________________
 Please indicate if you have any history of the following ailments in your family:
o ____ Tuberculosis; ____ Cancer; ____ Heart disease; ____ Ulcer ____ Diabetes;
____ Glandular problems; ____ Other(s): __________
 How would you describe your family’s concern for (Ie. Excessive or Limited):
o Diet: ______________________________________________________________
o Exercise: ___________________________________________________________
o Rest: ______________________________________________________________
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o Moral Climate: describe the moral atmosphere in which you were raised during the
first 18 years of your life (Ie. Overly permissive; overly strict):
__________________
___________________________________________________________________
III.
History of Personal Health
 Physical Status
o Describe your eating habits (i.e. do you eat healthy foods or often junk foods? Do
you eat regularly or sporadically; is your diet balanced, etc.?): _________________
___________________________________________________________________
o Do you have any addictions or cravings to sweets, drugs, alcohol, food?
__________
___________________________________________________________________
o Are you presently under any kind of medications for either physical or
psychological reasons? Yes: ___ No: ___

If yes, please list:
_________________________________________________
_______________________________________________________________
_______________________________________________________________
o Do you have any problems sleeping? Describe your sleeping patterns (I.e. do you
have restful sleep?):
___________________________________________________
o Are you having any recurring nightmares or disturbances? ____________________
___________________________________________________________________
o Do you allow for regular periods of rest and relaxation? ______________________
o Have you ever experienced any type of trauma (i.e. physical, emotional, or sexual
abuse; involvement in a severe accident, death of family member, etc.)? Explain:
___________________________________________________________________
___________________________________________________________________
o Do you have any physical disabilities? Describe: ____________________________
o Do you have a history of drug use?
_______________________________________
o How much alcohol do you drink? ________________________________________
o What is your present height and weight? And has your weight changed over the last
year? ______________________________________________________________
o When was the last time you felt well for a reasonable amount of time (Ie.
physically, emotionally, spiritually)?
_______________________________________________
 Emotional Health
o Describe briefly your earliest memory:
____________________________________
___________________________________________________________________
o Do you have periods or blocks of time in your past that you cannot remember?
Please describe: ______________________________________________________
___________________________________________________________________
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o Please indicate any of the following which you have or are presently struggling
with:

___daydreaming; ___lustful thoughts; ___inferiority; ___inadequacy;
___worry; ___doubts; ___fantasy; ___obsessive thoughts; ___insecurity;
___dizziness; ___headaches; ___compulsive thoughts ___blasphemous
thoughts
o Do you spend much time wishing you were somebody else or fantasizing that you
were somebody else or possibly imagining yourself living at a different time, place,
or under different circumstances? Explain:
_________________________________
___________________________________________________________________
o How many hours of TV do you watch per week? ___________________________
o List your five favorite programs:
_________________________________________
___________________________________________________________________
o How many hours do you spend a week reading? ____________________________
o What do you read primarily (Ie. newspaper, magazines, books)?
________________
___________________________________________________________________
o What type of music do you listen to, and what is the amount of time spent listening?
___________________________________________________________________
o Do you consider yourself to be an optimist or pessimist? Explain:
_______________
___________________________________________________________________
o Have you ever thought you were "cracking up", and do you presently fear that
possibility? Explain:
___________________________________________________
___________________________________________________________________
o Do you regularly read the Bible and/or a Devotional? When and to what extent?
___________________________________________________________________
o Do you find prayer difficult mentally? Explain: _____________________________
o When attending church or other Christian ministries, are you plagued with foul
thoughts, jealousies, and/or other mental harassments? Explain: _______________
___________________________________________________________________
o Concerning your emotions, indicate which of the following best describes you (X):

Readily express them

Express some of my emotions, but not all

Readily acknowledge their presence, but reserved in expressing them

Tendency to suppress my emotions

Find it safest not to express how I feel

Tendency to disregard how I feel since I cannot trust my feelings

Consciously or subconsciously deny them; too painful to deal with them
o Is there someone in your life whom you know that you could be emotionally honest
with right now (i.e., you could tell this person exactly how you feel about yourself,
life, and other people)? ________________________________________________
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o How important is it that you are emotionally honest before God, and do you feel
that you are? Explain: _________________________________________________
___________________________________________________________________
 Psychiatric History
o Have you had any previous treatment for psychological or emotional problems? If
yes, please describe. (Note: This includes any prior counseling) _______________
___________________________________________________________________
___________________________________________________________________
o Have you had any previous hospitalizations for psychological or emotional
problems? If yes, please describe:
________________________________________
___________________________________________________________________
o What is your current emotional/mental status? _____________________________
___________________________________________________________________
___________________________________________________________________
o Are you having any current suicidal thoughts or plans? If yes, describe:
__________
___________________________________________________________________
o Have you had any past problems or hospitalizations for suicidal attempts? If yes,
please describe (include dates):
__________________________________________
___________________________________________________________________
o Are you having any current homicidal or harmful thoughts or feelings, or any
anger-control problems? If yes, please describe: ____________________________
___________________________________________________________________
o Is there any mental or emotional illness or addictions in your family line? If yes,
please describe: ______________________________________________________
___________________________________________________________________