Republic of the Philippines

NUEVA VIZCAYA STATE UNIVERSITY

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STUDENT AFFAIRS AND SERVICES –
GUIDANCE SERVICES UNIT

STUDENT’S PERSONAL INFORMATION

_________ Semester, SY 20______ - 20______

NAME: ___________________________________________________________ Course & Year:_________________

(Family Name) (First Name) (Middle Name)
Home Address:________________________________________________________Contact No.__________________
Date of Birth: _____________________ Birth Place:_____________________________________________
Age: ______ Birth Order:_________ Number of siblings: _________ Are you adopted?  Yes
(pang-ilang anak ka) (ilan ang mga kapatid mo)  No
Gender:  Male  Female Citizenship: _________________ Religion:_______________________
Civil Status:  Single  Married
If married, Name of Spouse:___________________________________Occupation:____________________________
Ethnic Group:___________________ Dialect/s Spoken:_______________ Language/s Spoken: _________________
Father’s Name:__________________________________ Mother’s Name:_________________________________
Occupation: ______________Contact No._____________ Occupation:______________Contact No.____________
Highest Educational Attainment: Highest Educational Attainment:
 Elementary  Elementary
 High School  High School
 Vocational/Diploma Course  Vocational/Diploma Course
 College  College
 Graduate School  Graduate School

My parents’ combined monthly income is (please check [√] appropriate box):

 Less than P 10,000  P 30, 001 – P 40, 000
 P10, 000 - P20, 000  P 40, 001 – P 50, 000
 P20, 001 - P30, 000  P 100, 000 and above

My parents are:  Living Together  Separated, If separated:  mother remarried  father remarried

At your permanent address (home) whom do you live with (please check [√] appropriate box):
 immediate family (parents and siblings)
 immediate family (parents and siblings) and relatives (specify) ________________________
 relative/s (specify) ________________________
 others (specify) __________________________
Guardian: ____________________________________ Address:____________________________________________
Occupation:__________________________________ Contact No. _________________________________________
If living in a boarding house: Full name of Landlady/lord:________________________________________________
Address:___________________________________________________ Contact No. __________________________

SCHOOL/S ATTENDED ADDRESS YR. GRADUATED

ELEMENTARY___________________________________________________________________________________

SECONDARY ___________________________________________________________________________________

COLLEGE ___________________________________________________________________________________

VOCATIONAL ___________________________________________________________________________________
MEDICAL BACK GROUND (please check [√] appropriate box/es)
PHYSICAL INTERNAL PSYCHOLOGICAL
ALLERGIES ANEMIA VERBAL ABUSE
CLEFT PALATE ASTHMA PHYSICAL ABUSE
DEFORMITIES BONE FRACTURES SEXUAL ABUSE
DIFFICULTY IN BREATHING CANCER DEPRESSION
DIFFICULTY IN HEARING DIABETES FAINTING SPELLS
EYE DEFFECT HEART DISEASE
HAIRLIP HYPERTENSION
LEFT HANDED TUBERCOLOSIS

LIFESTYLE (please check [√] appropriate box)

How long do you play computer games a day? 1-2 hours 3-6 hours 7-12 hours
How long do you watch tv programs a day? 1-2 hours 3-6 hours 7-12 hours
How long do you surf the internet a day? 1-2 hours 3-6 hours 7-12 hours
How many sticks of cigarette do you consume 1-3 4-6 7-9 1 pack more than one
in a day? pack
How often do you drink alcoholic beverages? occasionally once a week everyday
Which of the following prohibited drugs have marijuana shabu coccaine others
you tried?
How much money do you save from your P10- P20 P21- P40 P41- P60 more than none
daily allowance? P61 pesos
Hobbies:

STUDENT’S WELLNESS
ASPECTS CONCERNS GOALS
(please check [√] the box that (what are you willing to do in
corresponds to your concern/s) order to overcome your
concern/s)
physical health
PHYSICAL physical strength
physical appearance
understanding feelings
EMOTIONAL/PSYCHOLOGICAL acceptance of limitations
appreciating oneself
resisting temptations
critical thinking
COGNITIVE reading comprehension
mathematical difficulty
financial support for school
FINANCIAL requirements
managing allowance
finding purpose of life
SPIRITUAL relationship with God
moral values
relationship with:
parent/s sibling/s
SOCIAL relative/s friend/s
teacher/s classmate/s
boardmates
landlord/landlady
CAREER course choice
future employment

LIST OF CONFIDANTS (MGA TAONG PINAGKAKATIWALAAN)

(rank the following people from 1-10. One (1) means the most trusted confidant, 10 means the least trusted confidant)
_____Boyfriend/Girlfriend _____ Sister _____ Spouse
_____ Mother _____ Friends _____ Teacher
_____ Father _____Guidance Counselor __________________ Others
_____Brother _____ Nun/ Priest /Pastor

I hereby attest to the truthfulness of the given information.

_____________________________________
(Signature of Student)