GCC STUDENT FORM A.

Western Mindanao State University

Guidance & Counseling Center
Zamboanga City

PERSONAL DATA FORM

(New Student)

1x1

TO THE STUDENTS:
The purpose of this form is to bring together all essential information that may
enable us to assist you in your specific need and difficulties.
All information in this form shall be kept confidential. Please fill in the blanks
carefully and sincerely.
New Student
Old Student
PERSONAL INFORMATION
Date: ___________________
Name: ____________________________________ Course & Year: ________________
Surname
First
Middle
Date of Birth: ______________________________ Place of Birth: _________________
Age: ____________ Gender: ________________ Civil Status: ___________________
Religion: ___________ Nationality: ____________ Language: _____________________
City Address: ______________________________ Tel. / Cellphone No.:_____________
Prov. Address: _____________________________ Ethnicity: ____________
FAMILY RECORD
Father
Name: ________________________
Put + if deceased
Place of Birth & Age: ____________
Address & Tel. No.: _____________
______________________________
Religion: ______________________
Nationality: ____________________
Occupation: ____________________
Name of Firm/Employer: __________
______________________________
Highest Degree/Grade: ____________
Schools Attended:_______________
Hobbies & Interests:_____________

Mother

Spouse (if married)

_____________________
Put + if deceased
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________

______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________

Which of his/her traits would you like to have? _________________________________

With whom would you rather discuss your problem? _____________________________
Marital Status of Parents: Check those which are applicable:
.

______ Parents married in the church

______ Parents married civilly
______ Parents living together

______ Parents separated

______ Father remarried
______ Mother remarried

No. of person living at home: Members of family ___________ Children ____________

Relatives ___________________ House helpers ________
Guardians, if not living with parents ____________________ Relation ______________
Language or Dialects spoken at home_________________________________________

List all the children in your family including yourself starting with the eldest. Put an x
opposite to your name. (if married list your own children)
Name

Sex

Age

______________
______________
______________
______________
______________
______________

______
______
______
______
______
______

____
____
____
____
____
____

Civil Status

School/
Occupation
_________ ___________
_________ ___________
_________ ___________
_________ ___________
_________ ___________
_________ ___________

Grade or Year
Company or Firm
__________________
__________________
__________________
__________________
__________________
__________________

EDUCATIONAL BACKGROUND
Name the schools you have ever attended. (Include grade school, high school and other
colleges)
School

Date of
Attendance

Grade/Year
Level

Honors/Award
Received

__________________
__________________
__________________
__________________

___________
___________
___________
___________

___________
___________
___________
___________

____________
____________
____________
____________

H.S. Subjects Liked

__________________
__________________
__________________

Grade
___________
___________
___________

Subjects Disliked
___________
___________
___________

Grade
____________
____________
____________

Approximate high school average ____________ Rank in class __________________

Course presently enrolled in ________________ Major ________________________
Other course previously enrolled in ___________________________________________
Reason for shifting/ Transferring _____________________________________________
Present Educational and Vocational Plans
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
How did you make this choice?
________ family suggestion ___________ teachers choice
________ family tradition
___________ following vocation of someone I admire
________ personal choice
Others (pls. specify) _____________________________
________ friends choice
_______________________________
If choice was not your own, what course would you rather take up? _________________
How did you come to this school?
________ personal choice ___________ friends recommendation
________ parents choice ___________ Others (pls. specify) ___________________
How much information do you have about the requirements of the course you are takingup:
___very much

____ much

____ enough

_____ very little

____ none

Where did you get this information? (Specify) __________________________________

Source of financial support in college:

_____ family
_____ savings
_____ part-time work

_____ government aid

_____ scholarship
Others: (pls. specify) __________________

Self-evaluation regarding scholastic standing. Check the following which apply to you:
_____ I barely passed most of my subjects
_____ I failed most of my subjects
_____ I am having a hard time passing my subjects
_____ I have difficulty with some of my subjects
_____ I fear I am going to fail this semester
_____ I am confident I can finish my course
_____ I am still adjusting to my studies
Other remarks
HEALTH RECORD AND LIVING CONDITIONS
Indicate as required: Physical Profile and Identification marks:
_____ Height
_____ Complexion

______ Weight
______ Others

______ Mole

_______wearing glasses

Physical Programs Participated:

______ aerobic fitness ______ weight lifting/ body building ________ games/ sports
______ stretching/ swimming ______ dancing/ gymnastics ______ others
Suffering from physical ailment:
_____ Allergies
______ Migraine/ Dizziness
______ Others
_____Asthma
______ Stomach Ache
Physician Handling: ______________________________
Where do you live? _______ Home
_______Boarding House _______ Others
_______ Renting a Room __________ Living with Relatives
How many are you in your present place now? __________________________________
How many persons share the room with you? ___________________________________
LEISURE TIME ACTIVITIES
List any social, religious, economic, educational activities.
Membership on Organization
On-Campus ___________________________________________
Off-Campus____________________________________________
Award Received __________________________________________________________
Organizations ____________________________________________________________
Hobbies & Interests _______________________________________________________
GENERAL PERSONALITY MAKE-UP
Check one or more of the following words which you feel describe your general
personality make-up.
___ friendly
___ reserved
___ stubborn
___ capable

___ unhappy
___ pessimistic
___ shy
___ self-confident

___ cheerful
___ lazy
___ submissive
___ excited

___ tolerant
___ calm
___ anxious
___ depressed
___ nervous
___ easily exhausted
___ quiet

___ jealous
___ talented
___ quick-tempered
___ cynical
___ tactful
___ conscientious
___ talkative

___ irritable
___ poor health
___ frequent daydreaming
___ sarcastic
___ lovable
___ aloof
Others _______________

Significant Events in Your Life: Explain briefly.

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
What things have caused you most humiliation or sense of failure?
______________________________________________________________
Have you had any counseling previously? _____ Yes

______ No

When? ___________________ With Whom? _______________________________

Briefly write what seem to be your particular problems in any area of your life.

List three names of persons connected in this university or community, who know you
personally.
NAME

OCCUPATION

___________________
___________________
___________________
___________________

____________________
____________________
____________________
____________________

ADDRESS
_____________________________
_____________________________
_____________________________
_____________________________

______________________________________________________________________

GUIDANCE AND COUNSELING ASSISTANCE

What help do you want to obtain from the Guidance and Counseling Center?

GUIDANCE COUNSELOR/ COORDINATOR