Republic of the Philippines

Department of Education
- Western Visayas
Region Vl
Division of Negros Occidental
DON HITARION G. GONZAGA MEMORIAT HIGH SCHOOT
GUIDANCE AND COUNSELING SERVICES

INDIVIDUAL INVENTORY RECORD

Date:_
LRN No.:

I. PERSONAL I NFORTI/IATION
Ham* Gender: ASe:-
(surname) (First Name) (Middte Name) Ci*il Statusr
Year and $ection: Date of Birth:
Complete Address: Flace of Birth:
EmailAddress: Height (cml:
Cellphone No.: Weight (kgi:
Person to be contacted in case of emergency:
Address: Relationship: Contact No.:
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-
II. EDUCATIONAL BACKGROUND -
TEVEL
scHooL scHoor PUBLIC/
DATES OF HONORS/
GRADUATED ADDRESS ATTENDANCE SPECIAL AWARDS
PRIVATE

Pre-elementary

Elementary

High fthool
(i7 ai8 c)e
o10 ()11
Nature of Schooling: ( ) Continuous { ) lnterrupted. Why?

III. HOME AND FAMILY BACKGROUND

NameofFather: Age:- ( )Living ( )Deceased
Educational Attainment: Occupation:
Name of Employer: Address of Employer:

Nameof Mother: Age:- { }tiving ( }Deceased

Educational Attainment: Occupation:
Name of Employer: Address of Employer:

Name of Guardian: Ate: _ Relationship:

Educational Attainment Occupation:
Name of Employer: Address of Employer:

Parent's Marital Relationship: {Kindly check)

( ) Married and Staying together t ) Single Parent
{ } Not Married and Living together ( ) Married but Separated
( ) Others (Pleose specify)
Number of children in the family including yourself: Number of Brothers: Number of sisters:
Number of brothers/sisters gainfully employed; Ordinal Position (1't child, 2nd- child, ect.)t
ls your brother/sister who is gainfully employed support your: (Kindly check)
( ) Family ( ) MV studies ( ) His/her own family

-
 Who finances your schooling? (Kindly check)
( )Parents { }Spouse { )Relatives ( }BrotherlSister
{ )Schotarship ( }Self-supportinglworkingstudent
How much is your weekly allowances? (Please specify)
Parents' Total Monthly lncome:
{ }BelowPhp5,000 ( }Php20,001-Php25,000 ( }Php40,001-Php45,000
{ }Phps,001-Php 1O000 { } Php25,001-Php30,000 { }Php4s,001-Php50,000
t )Php10,001-Php 15,000 { }Php30,001-Php35,000 ( }AbovePhp 50,fi}1
{ } Php 15,000 - Php 20, 000 ( } Php 35, 001- Php 40, fi}O ( } Others {Please specify)
Do you have a quiet place to study? {Kindly check) ( } Yes ( } No
Do you share your own room with anyone? (Kindly check) ( ) Yes ( ) No. lf yes, with whom?
Nature of Residence while attending school: (Kindly check)
{ } Family home ( } Bed spacer ( ) House of married brother/sister
( ) Relative's home ( ) Rented apartment ( ) Dorm {including baard & lodginq)
( ) Shares apartment with friends/relatives (Kindly underline)

IV. HEATITI
A. Fhydait
Bo you have pm*mr t*ith yurr {Kindly check)
YES NO lf Yer, please specfy YES NO lf Yes, please specify
Vision () {} Speech ( ) l
Hearing ()() Hearing ( ) )

B. Psycholagical
Previous Consultation
CONSULTED YES NO WHEN FOR WHAT?
Psychiatrist
Psychologist
Counselor

V. INTERESTS AND HOBBIES

A. Acodemic
(}MathClub(}ScienceClub(}others(Pleosespecify)-
( ) Debating Club ( )Quizze/s Club
What is/are your favorite subjects?
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? (Kindly check)
(}Athletics()Religiousorganization(}GleeClub{}others(Pleasespecify)-
( )Dramatics ( )ChessClub ( )Scouting
Occupational position in the organization:
(}officer{}Member(}Member(}others(Pleasespecify)-
Vl. SIGNf FICANT NOTES (For Guidonce Counselors
DATE INCIDENT REMARKS

tStudent's Signature over Printed Name)