Student No.
___________________
Form 1A -GCTS
Don Juan F. Avalon National Highschool
GUIDANCE, COUNSELING AND TESTING SERVICES
San Roque N. Samar
INDIVIDUAL INVENTORY RECORD FORM
__________________________
Date
Please PRINT clearly
I. PERSONAL INFORMATION
Name: _____________________________________________________ Gender: ___________ Age: ___________
(Surname)
(First Name)
(Middle Name) Civil Status: _________________________
Course, Year and Section: ______________________________________ Date of Birth: _______________________
Height (m): _________ Weight: __________ Complexion: _________ Place of Birth: _______________________
City Address: _______________________________________________ Email Address: _______________________
Provincial Address: ___________________________________________ Telephone No.: _______________________
High School General Average: ________ Religion: ________________ Mobile No.: _________________________
If working, please indicate the name and address of employer: ____________________________________________
Person to be contacted in case of accident or serious illness: _______________________________________________
Address: ________________________________ Relationship: _____________ Contact Number: ______________
II. EDUCATIONAL BACKGROUND
LEVEL
SCHOOL GRADUATED
SCHOOL ADDRESS
PUBLIC /
PRIVATE
DATES OF
ATTENDANCE
HONORS
RECEIVED/
SPECIAL
AWARDS
Pre-elementary
Elementary
High School
Vocational
College if any
Nature of Schooling:
Continuous
] Interrupted, Why? _____________________________________
III. HOME AND FAMILY BACKGROUND
Name of Father: ____________________________________________ Age: _____ [ ] Living [ ] Deceased
Educational Attainment:______________________________________ Occupation: ______________________
Name of Employer: __________________________________ Address of Employer:______________________
Name of Mother: ____________________________________________ Age: _____ [ ] Living [ ] Deceased
Educational Attainment: ________________________________________ Occupation: __________________
Name of Employer: __________________________________ Address of Employer: _____________________
Name of Guardian: __________________________________________ Age: _____ Relation:______________
Educational Attainment: ________________________________________ Occupation: __________________
Name
of
Employer:
__________________________________
Address
of
Employer:______________________
Parents Marital Relationship: (Please Check)
[ ] Single Parent
[ ] Married and staying together
[ ] Married but Separated
[ ] Not Married but Living Together
[ ] Others (please specify) _____________________
Number of children in the family including yourself:____ Number of Brother/s: ____ Number of Sister/s: ____
Number of brother/s or sister/s gainfully employed? _______ Ordinal Position (1st child, 2nd child etc. )_______
Is your brother/sister who is gainfully employed providing support to your: (Please Check)
[ ] family?
[ ] your studies?
[ ] his/her own family?
Who finances your schooling? [ ] Parents
[ ] Brother/Sister
[ ] Spouse
[ ] Scholarship
[ ] Relatives
[ ] Self-supporting/working student
How much is your weekly allowance? (please specify the amount) _____________________________________
Parents Total Monthly Income:
[ ] Below Php5,000
[ ] Php 15,001-Php 20,000
[ ] Php 5,001- Php 10,000 [ ] Php 20,001-Php 25,000
[ ] Php 10,001-Php15,000 [ ] Php 25,001-Php 30,000
[ ] Php 30,001-Php 35,000 [ ] Php 45,001-Php 50,000
[ ] Php 35,001-Php 40,000 [ ] Above Php 50,001
[ ] Php 40,001-Php 45,000 [ ] Others please specify
____________
Do you have a quiet place to study? (Please Check)
[ ] Yes [ ] No
Do you share your room with anyone? (Please Check) [ ] Yes [ ] No If yes with whom? ______________
Nature of Residence while attending school: (Please Check)
[ ] family home
[ ] bed spacer
[ ] house of married brother/sister
[ ] relatives house
[ ] rented apartment
[ ] dorm (including board & lodging
[ ] shares apartment with friends/relatives (Please Underline)
IV. HEALTH
A. Physical
Do you have problems with (Please Check)
Your Vision
Your Hearing
YES
[ ]
[ ]
NO
[ ]
[ ]
If Yes, please specify
YES
_________________ Your speech
[ ]
_________________ Your general health [ ]
NO
If Yes, please specify
[ ]
[ ]
________________
________________
B. Psychological
Previous Consultations
CONSULTED
YES
NO
WHEN
FOR WHAT?
Psychiatrist
Psychologist
Counselor
V. INTERESTS AND HOBBIES
A. Academic
[ ] Math Club
[ ] Science Club
[ ] Others, please specify
[ ] Debating Club
[ ] Quizzers club
What is/are your favorite subject/s? __________________________________________________________
What is /are the subject/s you like least? _______________________________________________________
B. Extra-Curricular
What are your hobbies? Write them in the order of your preferences.
1. ___________________________________________
3.
____________________________________ 2. ___________________________________________
4. ____________________________________
Which of the following organizations have you participated in and which interest you most? (Please specify)
[ ] Athletics [ ] Religious organization
[ ] Glee Club [ ] Others, please specify ______________
[ ] Dramatics [ ] Chess Club
[ ] Scouting
Occupational position in the organization: [ ] Officer
[ ] Member [ ] Others, please specify__________
VI. TEST RESULTS
DATE
NAME OF TEST
RS
PR
DESCRIPTION
VII. SIGNIFICANT NOTES (For Guidance Counselors only)
DATE
INCIDENT
REMARKS
_________________________
(Students Signature)
