Republic of the Philippines

Department of Education
NATIONAL CAPITAL REGION
SCHOOLS DIVISION OFFICE OF QUEZON CITY
JUSTICE CECILIA MUÑOZ PALMA SENIOR HIGH SCHOOL
PASEO DEL CARMEN ST., AMLAC VILLE, PAYATAS B, QUEZON CITY
Tel. No. (02) 281-53-04
GUIDANCE AND COUNSELING OFFICE

STUDENT INDIVIDUAL INVENTORY FORM

Dear Students: Kindly fill-out this form. The following information will aid the Guidance Office to
develop a program to address your needs. Rest assured that the information provided will be
treated with confidentiality. Thank you.
_______________________________________________________________________________

A. PERSONAL DATA
LEARNER’S REFERENCE NUMBER: ______________________________ DATE FILLED: _____________
NAME OF STUDENT: ________________________________________ NICKNAME:_______________
AGE: __________________ DATE OF BIRTH: __________________ PLACE OF BIRTH: _____________
SEX: __________________ BIRTH ORDER AMONG SIBLINGS: ___________________ HEIGHT: ______
WEIGHT: _______________________ BLOOD TYPE: __________________
PRESENT ADDRESS:
__________________________________________________________________________________
__________________________________________________________________________________
____________________________________________.
LANDLINE: _________________________________ CELLPHONE NO. __________________________
E MAIL: _____________________________________ FB LINK: _______________________________
RELIGION: ____________________________________
IF WORKING, KINDLY INDICATE THE ADDRESS OF EMPLOYMENT: ____________________________________________
Person to be contacted in case o! accident or serious illness:
___________________________________________
Address: ______________________________ Relationship: __________ Contact Number: _______

Student Status: ___ Single ____ Married ______ Solo Parenting ______ With Partner
Means of Living: _____________________________________________
Any urgent academic/school concern? _______________________________________________
__________________________________________________________________________________

B. FAMILY DATA
FATHER’S NAME: _____________________ AGE: ______________ CP # _______________
EDUCATIONAL ATTAINMENT: _________________________ OCCUPATION: ________________
MOTHER’S NAME: ___________________ AGE: _______________ CP # ______________
EDUCATIONAL ATTAINMENT: _________________ OCCUPATION_____________________________
NUMBER OF SIBLINGS: _________________________
BROTHERS SISTERS
______________________________________ __________________________________________
______________________________________ __________________________________________
______________________________________ __________________________________________
______________________________________ __________________________________________
______________________________________ __________________________________________
Parents’ Marital Status:
O Parents married in church
 Republic of the Philippines
Department of Education
NATIONAL CAPITAL REGION
SCHOOLS DIVISION OFFICE OF QUEZON CITY
JUSTICE CECILIA MUÑOZ PALMA SENIOR HIGH SCHOOL
PASEO DEL CARMEN ST., AMLAC VILLE, PAYATAS B, QUEZON CITY
Tel. No. (02) 281-53-04
O Single parent
O Parents married civilly
O Parents living together
O Parents living together not legally married
O Parents separated
___ Father remarried
___ Mother remarried
Child is living with O Father O Mother
Name of Person if child is not living with parent/s: ______________________ Relationship to
child______________________________________________
C. HEALTH CONCERN:
COVID 19 VACCINATION INFORMATION:

1ST DOSAGE: DATE OF VACCINATION _________ BRAND OF VACCINE ____________PLACE ________

2ND DOSAGE: DATE OF VACCINATION _________BRAND OF VACCINE ____________ PLACE ________

BOOSTER: DATE OF VACCINATION _______________ BRAND OF VACCINE _______ PLACE ________

STUDENT’S HEALTH INFORMATION Height: ________ Weight: ________

Have experienced any of the following illnesses? Pls. check those that have affected you for the past
5 years up to the present:
_____ asthma _____ hearing defects _____ nervousness
_____ convulsion or fits _____ heart diseases _____ pneumonia
_____ diabetes _____ hernia _____ smallpox
_____ epilepsy _____ influenza _____ stammering
_____ eye defects (pls. specify) _____ mumps _____ typhoid fever
_____ malaria _____ tuberculosis _____ fainting spells
_____ measles _____ frequent headaches
Do you have other special needs and concerns (e.g. ADD, ADHD, LD, etc.)? Please specify.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Do you have allergies (e.g. food, medicine etc.)? Please specify.
____________________________________________________________________________
____________________________________________________________________________

PERSONALITY INFORMATION
Check those which you feel best describe your general personality make-up:
_____ aggressive _____ honest _____ pessimistic _____ anxious
_____ independent _____ quick _____ calm _____ irritable
_____ quiet _____ cheerful _____ jealous _____ sarcastic
_____ confident _____ lacks motivation _____ sensitive _____ conscientious
_____ lazy _____ shy _____ courteous _____ lovable
_____ smart _____ depressed _____ moody _____ stubborn
 Republic of the Philippines
Department of Education
NATIONAL CAPITAL REGION
SCHOOLS DIVISION OFFICE OF QUEZON CITY
JUSTICE CECILIA MUÑOZ PALMA SENIOR HIGH SCHOOL
PASEO DEL CARMEN ST., AMLAC VILLE, PAYATAS B, QUEZON CITY
Tel. No. (02) 281-53-04
_____ dull _____ neat _____ submissive _____ easily confused
_____ nervous _____ talented _____ easily excited _____ optimistic
_____ talkative _____ easily tired _____ passive _____ thoughtful
_____ feels inferior _____ patient _____ withdrawn _____ friendly
_____ persevering Others, please specify: ___________________________________________

SOCIAL RELATIONSHIPS
Please check any of the items that apply to you.
At home:
_____ discusses problems with father _____ asserts himself/herself
_____ discusses problems with mother _____ demanding
_____ enjoys the company of siblings _____ goes only with familiar people
_____ enjoys family outings/affairs _____ prefers to be left alone
_____ friendly with household help _____ often fights with people in the house
_____ generous with his/her things _____ difficult to deal with
Others, please specify: __________________________________________________
In school:
_____ would rather be a follower _____ is looked as a leader
_____ friendly with the people in school _____ afraid of teachers/other students
_____ enjoys the company of classmates _____ would rather be alone
_____ interested in class activities _____ goes only with familiar people
_____ asserts himself / herself _____ always in trouble with classmates
Others, please specify: ___________________________________________________

OTHER PERTINENT INFORMATION

Relate significant events / unforgettable experiences that happened in your life.

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
List down any difficulties, conflicts, obstacles or worries that you think disturb you.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
In what way could the guidance counselor help you at this time? Please write other information,
which you think is vital information to your development.
____________________________________________________________________________
____________________________________________________________________________

______________________________ _________________________
NAME AND SIGNATURE OF STUDENT DATE OF SUBMISSION

_____________________________ _________________________
CLASS ADVISER PARENT/GUARDIAN
 Republic of the Philippines
Department of Education
NATIONAL CAPITAL REGION
SCHOOLS DIVISION OFFICE OF QUEZON CITY
JUSTICE CECILIA MUÑOZ PALMA SENIOR HIGH SCHOOL
PASEO DEL CARMEN ST., AMLAC VILLE, PAYATAS B, QUEZON CITY
Tel. No. (02) 281-53-04
_________________________________
GUIDANCE TEACHER