PUPIL PERSONAL DATA FORM

Republic of the Philippines

DEPARTMENT OF EDUCATION
Region _____
Division of ___________________
DISTRICT OF ____________________________

Name: School
(Surname) (Given Name) (Middle Name)

Sex Place of Birth Date of Birth

(Barangay) (Town) (Province)

II. FAMILY DATA

NAME OF PARENT/GUARDIAN Date of Birth Place of Birth Educ'l Attainment Religion Occupation Business A

No. of Children in the family: Older Children: Younger Children

Boys Boys Boys
Girls Girls Girls
Total Total Total
LANGUAGE USED AT HOME:
OTHER LANGUAGES SPOKEN:

III. ELEM. SCHOOL STANDARD TEST RECORD

TEST FORM DATE SCORE GRADE EQUIVALENT AGE EQUIVALENT PERCENTAGE FILE C.A.
RANK
 (Date of Entrance)

Living/ Death
Business Address
Dead Date/Cause

r Children:
oys
irls
otal

M.A. I.Q.
 IV. WITHDRAWAL RECORD VI. RE-ENTRY RECORD
Date Cause Transferred to Date Cause

CODE USED: IV 1. Transferred 6. Home Chores V. 1. Transferred from another school

2. Employment 7. School Atmosphere 2. Loss of job
3. Poor Health 8. Financial Difficulty 3. Health regained
4. Marriage 9. Death 4. Desire for additional schooling
5. Poor Scholarship 10. Distance of home 5. Permission by school authorities

IMMUNIZATION AND IMMUNITY TEST

VI. HEALTH EXAMINATION/INSPECTION
Date Result Date Result Date Result

School Allergy Test

Grade BCG

Date CDT

Age Diphtheria

Height Pertussis

Weight Small Pox

Vision Tetanus

Hearing

Flouroscopy Tuberculine Test

Circulatory System

Heart FIELD VISITS

Blood Pressure
Date Dwelling Facilities Study Conditions Surroundings Waste Disposal
Nervous System

Glands

Eyes and Ears

Nose, Mouth & Throat

Skin and Scalp

Orthopedics

Intestinal Parasitism

Othetr Diseases

CODE USED 1. Ears & Eyes 2. Nose, Mouth & Throat 3. Skin & Scalp Orthopedics Other Diseases Actio
a. Granular eyelids a. Nasal obstruction a. Pediculosis a. Deformities (Indicate diseases)
a. Floroscopy b. Inflamed eyes b. Dirty teeth b. Tinea Flava b. Faulty posture
c. Squinting eyes c. Defective teeth and gums c. Scabies
b. Flourography d. Defective throat d. Enlarged tonsils d. Ringworm
e. Inflamed throat e. Ulcers
f. Minor Injuries
 Received from

DISEASE EXPERIENCE
Disease Inclusive Date Disease Inclusive Date

Allergy Mumps

Chicken Pox Parasitism

Diphtheria Rheumatism

Tonsilitis

Chronic Cough
Typhoid Fever
Dysentery

Malaria
Whooping Cough
Measles

Yaws

Home
Recommendations Teacher or Teacher-Nurse
projects

Action Taken Field Visits

R - referral E = Excellent
T - treated G =Good
O - further F = Fair
obervation N = Needs
C - corrected Improvement
 VII. GRADUATION FACTS X. FOLLOW-UP RECORD

A. EDUCATIONAL B. WORK/EXPERIEN

Graduated
(Month-Day-Year) Date
Record Sent to: Working
Full/Part Time
Elementary School Cooperator
(Name of School (Date Entered) (High School) Date
Working
Date Entered Full/Part Time
Rank in class (First Ten) Cooperator
Location Comments
VIII. EDUCATIONAL & VOCATIONAL PLANS DATE REPORT
Fifth Grade
Sixth Grade

IX. OUT-OF-SCHOOL ACTIVITIES

Fourth Grade
Fifth Grade
Sixth Grade

XI. SIGNIFICANT NOTES

GRADE TEACHER R E M A R K S
Signature
PERIENCE
Designation