Republic of the Philippines

Department of Education
Region VIII (Eastern Visayas)
Division of Leyte
Dagami South District
ORMOCAY ELEMENTARY SCHOOL
Dagami, Leyte

ANECDOTAL RECORD

Name: _______________________________ Date of Birth: _____________________

School: ORMOCAY ELEMENTARY SCHOOL Age: ________
Doesn't Apply Applies Somewhat Certainly Apply
Statement
1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Very restless, open running or
jumping up and down hardly ever still                                    
Through want from school                                    
 Squirmy, pigsty child                                    
 Open destroys owned or others
belongingness                                    
 Frequently fights with other children                                    
 Not much liked by other children                                    
 Often- worried, worries about many
things                                    
 Tends to do things on his own rather
solitaire                                    
 Irritable – is quick to fly off the
handle                                    
 Often appears miserable, unhappy,
and tearful or distress                                    
 Has twitches, mannerism, or ticks of
the face or body                                    
 Frequently sucks thumbs or finger                                    
 Tends to be absent from school for
trivial reasons                                    
 Is often disobedient                                    
 Has poor concentration                                    
 Tends to fearful or afraid of new
things or new situations                                    
 Fussy or over particular child                                    
 Often tells lies                                    
 Has stolen things in one or more
occasions                                    
 Has wet or soiled self at school this
year                                    
 Often complains of pains or aches                                    
 Has hard cheers on arrival at school
or has refused to come into the room
or building this year                                    
 Has a stutter or stammer                                    
 Has other speech difficulties                                    
 Bullies other children                                    

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Signature of Student Signature of Parent