Republic of the Philippines
Department of Education
Province of Cebu
Cordova National High School
Day-as, Cordova, Cebu
Guidance Form 1
INDIVIDUAL INVENTORY RECORD
I. PERSONAL DATA
Name: _________________________________________________________________ Sex : ________ Age : ______
(Last Name) (First Name) (Middle Name)
Date of Birth : _____________________________ Place of Birth : _________________ Religion : _________________
Home Address : ___________________________ Citizenship : ___________________ Contact Nos. : _____________
II. FAMILY BACKGROUND
FATHER MOTHER
Name
Date of Birth
Age
Occupation
Educational Attainment
Home Address
Children in the Family:
NAME SEX AGE EDUCATIONAL CIVIL OCCUPATION
ATTAINMENT STATUS
(If you are not living with your parents, pls. fill this out)
GUARDIAN
Name
Date of Birth
Age
Occupation
Educational Attainment
Home Address
Marital Condition of Parents :
( ) married and living together ( ) separated ( ) solo parent ( ) one parent is deceased ( ) both parents are deceased
Source of Income/Livelihood: ___________________________________
Living With : ( ) parents ( ) grandparents ( ) relatives ( ) friends ( ) others (pls. specify)_____________
Type of Discipline : ( ) lax ( ) strict ( ) democratic
Ambient of Growth : ( ) city ( ) province
Birth Rank : _________________________________________________
Problems met/experienced with:
Father
Mother
Brother/s
Sister/s
Others (specify)
III. SCHOLASTIC RECORD
NAME OF SCHOOL HONORS/AWARDS RECEIVED
Elementary
High School
IV. MEDICAL HISTORY
Height : _________ Weight : __________ Visual Acuity : ______________________ Hearing : ________________
Do you get sick often? ( ) yes ( ) no Frequency _____________________________________
Illnesses since childhood : __________________________________________________________________________________
Physical disabilities/handicaps : ______________________________________________________________________________
Do you have a permanent/family doctor? ___________________ How often do you visit the doctor? ___________________
Additional Health Information (pls. specify):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
V. PERSONALITY, ATTITUDES & INTERESTS
Identify at least 5 most disturbing problems that you have presently encountered. Number them from 1-8 according to their degree
of significance.
Academic Failures Health Problem Pre-Marital Sex Others (pls. specify)
Alcoholism Communication Religion/Faith
Boy-Girl Relationship Love Life Conflict With Peers
Broken Home Homosexuality Study Habit
Drug Addiction Inferiority Complex Depression
Emotional Problem Masturbation
Financial Problem Parent-Child Relationship
What problem would you like to discuss with a counselor? (pls. check)
______ job ______ education ______ finance ______ relation with others
______ personal ______ others (pls. specify) ___________________________________________________________
What kind of work have you done?
Job Inclusive Dates Did you like it? Why?
_________________ ______________________ ___________ _______________________________________
_________________ ______________________ ___________ _______________________________________
What occupations/jobs would you like to enter?
Job Reason/s
_________________ ____________________________________________________________________________
_________________ _____________________________________________________________________________
Hobbies: ________________________________________________________________________________________________
Talents/Skills: ____________________________________________________________________________________________
Interests: ________________________________________________________________________________________________
Sports___________________________________________________________________________________________________
Most Liked Subjects: _______________________________________________________________________________________
Least Liked Subjects: ______________________________________________________________________________________
Plans For The Future: ______________________________________________________________________________________
Please draw a sketch map of your house from the barangay hall. (*for Home Visitation purposes only)
Barangay Hall
