Name of learner:

Date of Birth: Age: _

Grade/Year Level: Gender: _
Address: _
Number of Siblings: _
Birth Order: _
Parents Information
Mother: Age: _
Occupation: Educational Attainment: _
Father: Age: _
Occupation: Educational Attainment: _
Learner’s Physical Aspect:
Health
1. Did the mother meet any complications during her pregnancy
with the learner? [ ]Yes [ ]No
2. Has the learner encounter serious health problem as a child?
[ ]Yes [ ]No
3. What kind of food does the learner most prefer as a child
and at present? Does he/she prefer to eat healthy foods like
vegetables than other processed foods? [ ]Yes [ ]No
4. Are you the one who took care of him/her since he/she was
young? [ ]Yes [ ]No
Learner’s Social Aspect:
1. Is the learner [ ]friendly and outgoing or [ ]shy and a
loner?
2. Does the learner prefer to [ ]play alone or [ ]play with
friends?
3. Do you allow your child to play outside and mingle with
other kids? [ ]Yes [ ]No
Emotional-Moral Aspect:
1. Do you set expectation for your child? [ ]Yes [ ]No
2. Do you scold your child when they don’t do well in school?
[ ]Yes [ ]No
3. Are you emotionally close to your child? [ ]Yes [ ]No
4. Does your child open up with you about what they feel and
about the things that are bothering them? [ ]Yes [ ]No
Learner’s Cognitive Aspect:
1. What are the child’s interest? _
2. What is he/she good at in school? _
3. In what subject does he/she have difficulty? _
4. Do you monitor his/her performance in school? _
5. How do you motivate your child to learn? _
Parent Interview Form

The Learner’s Development Profile

Name of the learner: Age: _
Date of Birth: Gender: _
Grade/Year Level: _
Name of School: _
Date of Home Visit: _

Family Profile
Number of Siblings: _
Birth Order: _
Parents
Mother: Age: _
Occupation: Educational Attainment: _
Father: Age: _
Occupation: Educational Attainment: _

Physical Development
_
_
_
Social Development
_
_
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Emotional-Moral Development
_
_
_
Cognitive Development
_
_
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Findings
_
_
_
Conclusion
_
_
_
Recommendations
_
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_
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