PUPIL PERSONAL DATA FORM

Republic of the Philippines

DEPARTMENT OF EDUCATION
Region _____
Division of ___________________
DISTRICT OF ____________________________

Name: School
(Surname) (Given Name) (Middle Name)

Sex Place of Birth Date of Birth

(Barangay) (Town) (Province) (Date of Entrance)

II. FAMILY DATA

Educ'l Living/ Death
NAME OF PARENT/GUARDIAN Date of Birth Place of Birth Religion Occupation Business Address
Attainment Dead Date/Cause

No. of Children in the family: Older Children: Younger Children:

Boys Boys Boys
Girls Girls Girls
Total Total Total
LANGUAGE USED AT HOME:
OTHER LANGUAGES SPOKEN:

III. ELEM. SCHOOL STANDARD TEST RECORD

TEST FORM DATE SCORE GRADE AGE PERCENTAGE C.A. M.A. I.Q.
EQUIVALENT EQUIVALENT FILE RANK
 IV. WITHDRAWAL RECORD VI. RE-ENTRY RECORD
Date Cause Transferred to Date Cause Received from

CODE USED: IV 1. Transferred 6. Home Chores V. 1. Transferred from another school

2. Employment 7. School Atmosphere 2. Loss of job
3. Poor Health 8. Financial Difficulty 3. Health regained
4. Marriage 9. Death 4. Desire for additional schooling
5. Poor Scholarship 10. Distance of home 5. Permission by school authorities

IMMUNIZATION AND IMMUNITY TEST DISEASE EXPERIENCE

VI. HEALTH EXAMINATION/INSPECTION Inclusive Inclusive
Date Result Date Result Date Result Disease Date Disease Date

School Allergy Test Allergy Mumps

Grade BCG Chicken Pox Parasitism

Date CDT Diphtheria Rheumatism

Age Diphtheria Tonsilitis

Chronic
Height Pertussis Cough
Typhoid Fever
Weight Small Pox Dysentery

Vision Tetanus Malaria Whooping

Cough
Hearing Measles
Tuberculine
Flouroscopy Test Yaws

Circulatory System

Heart FIELD VISITS

Blood Pressure Home Teacher or Teacher-
Date Dwelling Facilities Study Conditions Surroundings Waste Disposal Recommendations
projects Nurse
Nervous System

Glands

Eyes and Ears

Nose, Mouth & Throat

Skin and Scalp

Orthopedics

Intestinal Parasitism

Othetr Diseases

CODE USED 1. Ears & Eyes 2. Nose, Mouth & Throat 3. Skin & Scalp Orthopedics Other Diseases Action Taken Field Visits
a. Granular eyelids a. Nasal obstruction a. Pediculosis a. Deformities (Indicate diseases)
a. Floroscopy b. Inflamed eyes b. Dirty teeth b. Tinea Flava b. Faulty posture R - referral E = Excellent
c. Squinting eyes c. Defective teeth and gums c. Scabies T - treated G =Good
b. Flourography d. Defective throat d. Enlarged tonsils d. Ringworm O - further F = Fair
e. Inflamed throat e. Ulcers obervation N = Needs
f. Minor Injuries C - corrected Improvement
 VII. GRADUATION FACTS X. FOLLOW-UP RECORD

A. EDUCATIONAL B. WORK/EXPERIENCE

Graduated
(Month-Day-Year) Date
Record Sent to: Working
Full/Part Time
Elementary School Cooperator
(Name of School (Date Entered) (High School) Date
Working
Date Entered Full/Part Time
Rank in class (First Ten) Cooperator
Location Comments
VIII. EDUCATIONAL & VOCATIONAL PLANS DATE REPORT
Fifth Grade
Sixth Grade

IX. OUT-OF-SCHOOL ACTIVITIES

Fourth Grade
Fifth Grade
Sixth Grade

XI. SIGNIFICANT NOTES

GRADE TEACHER R E M A R K S
Signature Designation