PERSONAL DATA INVENTORY-AY 2026-2027

PERSONAL DATA INVENTORY
CONFIDENTIAL
STUDENT CONSENT,
I understand that the Guidance and Testing Office (GTO) will collect my data and will only be ACCESSED when the academic year begins and the succeeding days thereafter when I am officially enrolled. I also understand that GTO is required to keep my counseling records until such time these documents are due for disposal based on SMU data privacy retention policy. Any information or counseling records that I provide are strictly confidential, except in life threatening situations, suicide, cases of suspected client abuse, or when released otherwise required by law, and for medical reasons. The information about counseling will not appear on my academic record.

I have read, understood, and agreed to the terms in the statement of confidentiality and informed consent. I therefore certify that the information I provided are true and correct. I understand that lying or giving false information will be a violation of the Student Discipline stated under Unacceptable Student Conduct will be dealt accordingly which may result to suspension to non-readmission (refer to Undergraduate Student Handbook under Code of Student Discipline page 109, number 25).
Signature*
Date Signed*

MonthDayYear
Date
I. PERSONAL INFORMATION
Name*

First NameMiddle NameLast Name
Gender:*
Age:*
Preferred Course:*
Birth Date:*

MonthDayYear
Date
Contact number/s:*
Format: (000) 000-0000.
Birth Place:*
FreshmenTransferee
Year Level if Transferee:
Email Address:*
example@example.com
Ethnicity (ex. Ilokano, Gaddang, Tuwali, etc.):*
Religion:*
Name of spouse if married:
Occupation of spouse:
No. of children if married:
Home address:*
Family homeRelative's houseApartment/dorm/boarding houseHouse of married brother/sisterHouse of brother/sister
Name of Guardian to be contacted in case of emergency:*
Contact no:*
Format: (000) 000-0000.
Address:*
Your relationship with the guardian:*

II. EDUCATIONAL BACKGROUND*

Rows	Name of School Graduated Or School last attended	Year Graduated	Honors/awards received
Elementary
Junior High School
Senior High School
College

Rows	At Home	At School
1. I easily talk about my feelings with someone.
2. I panic or have a habit of being nervous all the time.
3. I am pessimistic w/ my thinking and decisions.
4. I always have the feeling of nausea, dizziness or heart pounding most of the times.
5.I encounter the things I fear or phobic for.
6.I worry about things which hardly exist.
7. I easily get irritated, angry and hardly control my feelings.
8. I fear the tendency of being disliked/ judged/rejected by others.
9. I experienced being scolded, shouted or slapped at.
10. People made fun of me.
11. I am touched, grabbed, or pinched in a sexual way.

Rows	Rating (0 10)
1. From 0 10, how often have you had thoughts about suicide for the past Two Weeks? (0=Never, 10=Everyday)
2. From 0 - 10, how much control have you had over these thoughts of suicide for the past two weeks? (0 = No control, 10 = Full control/I can easily control the thoughts)
3. From 0 - 10, how close have you come to making a suicide attempt for the past two weeks? (0 = Not close at all, 10 = Already Made an attempt)
4. From 0 - 10, to what extent have you felt tormented or distress by thoughts about suicide for the past two weeks? (0 = Not at all, 10 = Extremely distress/stressed out)
5. From 0 - 10, how much have thoughts about suicide interfered/distracted you with your ability to carry out daily activities, such as Academics, Household tasks or Personal activities for the past two weeks? (0 = Not at all, 10 = Extremely Distracted/disturbed)

Rows	Answers (You may state it in Tagalog)
1. If Yes, kindly specify how did you hurt yourself physically but with NO intention to die: (ex. Cut wrists, arms, etc.)
2. If Yes, Kindly specify the reason/s why you Hurt/hurting yourself physically: (ex. To feel something, because my friends are doing, etc.)
3. If Yes, kindly specify how old are you when you FIRST intentionally hurt yourself but with NO intention to die.

Rows	1	2	3	4	5
1. I establish specific goals for my own performance.
2. Every time I accomplish something WELL, I like to treat myself to something or an activity I especially enjoy.
3. I make a point to keep track of how well I'm doing at work (school).
4. I tend to get down or blame myself in my mind when I have performed poorly.
5. I use my imagination to picture myself performing well on important tasks.
6. I think about my own beliefs and assumptions whenever I encounter a difficult situation.
7. My past experiences have prepared me well for my future.
8. Feel I am growing and changing in positive ways.
9.1 am having hard time to believe that my life has purpose
10. I feel sure of myself in most situations.

Rows	Date	Incident	Concern	Intervention	Counselor-in- charge
1
2
3
4
5
6
7
8
9
10

PERSONAL DATA INVENTORY

STUDENT CONSENT,

I. PERSONAL INFORMATION

III. HOME AND FAMILY BACKGROUND

IV. MEDICAL HISTORY & MENTAL HEALTH CHECKLIST

V. SHORT SELF POSITIVE BEHAVIORS SURVEY

VI. Counselor's Note (for guidance counselor's use)

Rows	Name of Sibling including student (In Order)	Age	Civil Status	Work address/School address
1
2
3
4
5
6
7
8
9
10