Department of Education

Region IV – A CALABARZON
City Schools Division of Dasmariñas
STA. CRUZ ELEMENTARY SCHOOL
BRGY. STA. CRUZ I, CITY OF DASMARIÑAS 4115

ANECDOTAL RECORD FORM

Name of Pupil _________________________________________
Kindergarten Grade I Grade II Grade III Grade IV Grade V Grade VI
Characteristics of Problems
S.Y. S. Y. S. Y. S. Y. S. Y. S. Y. S. Y.
CHRONOLOGICAL AGE
Biological Age
Body Age
Brain Age
Developmental Age
Intelligent Quotient
Weight
Height
BEHAVIORAL PROBLEMS
Anxiety
Depression
Trauma
Cultural Diversity
School Refusal
Body Image
Quarrelsome
Cheating/Stealing/Lies
Talkative
Gossips
Disobedient
Family Relationships:
Belongingness
Positive mental health
Mental health
Mindfulness
ADHD (Attention Deficit Hyperactivity
Disorder)
Neuro-psychological problems
Inherited factors
Peer influences
Parenting practices
Adverse social circumstances
(Bullying)
PERSONALITY PROBLEMS
Withdrawal or timid
Moody
Selfish
Tantrums
Paranoid personality disorder
Anti-social disorder
Avoidant personality disorder
Dependent personality disorder
Obsessive-compulsive personality disorder
Borderline Personality Disorder
Fear of abandonment
Unstable relationship
Unclear or unstable self-image
Impulsive
Self-destructive
Self-harm
Extreme emotional ways
Chronicle feelings of emptiness
Explosive anger
ADJUSTMENT PROBLEMS
Dislikes games/companions
Dislikes school routines
Repeat one or more grades
Falling in subjects
Relays Truant/Cutting classes
Habitual Tardiness
Irregular Attendance
Refuse to participate in schools activities
Learning Disability
Intellectual Disability
ENVIRONMENTAL PROBLEMS
Health habits
Eating habits
Home chores
PHYSICAL DEFECTS
Vision
Hearing
Harelip
Sickly
Skin Disease
Speech Defects
Down Syndrome
Cerebral Palsy
SOCIALPROBLEMS
*Can’t get along with
Teachers
Classmates
Friends
Family
EMOTIONAL PROBLEMS
Easily cries
Daydreams
Sensitive
INTELLECTUAL HANDICAPPED
Slow learner
Non-reader
Name of Teacher
Signature
Instructions: Observe pupil carefully and indicate with

if the child has more of a given characteristics

if the child has least of a given characteristics

if the child has serious problem if need of urgent assistance

Grade Level Date Incident Comments Observer

Kindergarten
I
II
III
IV
V
VI

Grade Level Adviser School Year Signature

Kindergarten
I
II
III
IV
V
VI