UNIVERSITY OF THE EAST

RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER, INC.

#64 Aurora Boulevard, Barangay Doña Imelda, Quezon City 1113

GUIDANCE AND COUNSELING OFFICE

INDIVIDUAL INVENTORY RECORD
Photo
Date: _______________________
November 1, 2020 1X1

I. PERSONAL INFORMATION
Ponce, Angelica Christine Palattao
Name:_______________________________________________________ Nickname:________________
26, 2001 Female Single
Date of Birth:________________________ Gender: ____________ Civil Status:_______________________
May
Place of Birth:_______________________
Pasig City Religion:_________________
Catholic Citizenship:________________
Filipino
City Address:___________________________________________________________________________
#6 F. Antonio Street Barangay Salapan San Juan City
#6 F. Antonio Street Barangay Salapan San Juan City
Permanent Address: _____________________________________________________________________
82878583
Home Tel no:_______________ Mobile No:__________________
09454958511 E-mail:___________________________
poncea0285@uerm.edu.ph

II. FAMILY
FATHER MOTHER
Name Jose Marlon J. Ponce Anie Jane P. Ponce
Citizenship Filipino Filipino
Occupation Unemployed Fragrance Adviser
Contact No/s. 09454958511 09179640962
Number of Siblings: _____________
None Birth Order: ___________

PARENTS’ MARITAL STATUS:

( * ) Married and Staying Together ( ) Married but Separated ( ) Not Married ( ) Single Parent
( ) Widow/Widower ( ) Others, please specify: _________________

LIVING WITH:
( * ) Both Parents ( ) Mother Only ( ) Father Only ( ) Guardian ( ) Others_______________

GUARDIAN (if not living with parents)

Jose Marlon J. Ponce
Name:__________________________________________________ Father
Relationship:______________________
Mobile No. ____________________________
09454958511 Email Address: ______________________________________
st.elmosfire1973@gmail.com

Education Name of School Address Year Graduated

Tertiary (if transferee) Immaculate Heart Of Mary College 54 Aurora Blvd. Quezon City 2013
Senior High School Immaculate Heart Of Mary College 54 Aurora Blvd. Quezon City 2020
Living condition while attending school: [ * ] Staying at home with family [ ] Bedspacer/Dorm [ ] Relative’s house
[ ] Rented apartment/Condominium [ ] Others, please specify: _______________________________________

III. INTERESTS & HOBBIES (Please discuss briefly)

CAT Marshal, Class Officer (President), Red cross Organizational Member
A. Academic Organizations: _________________________________________________________________
B. Extra-Curricular Activities: ________________________________________________________________
Badminton Club, and
Senior
Marian
Aspirant,
Youthand
Choir
Marian Youth Choir
C. Community Participation: _________________________________________________________________
None

Your privacy is important to us, hence, the institution developed a privacy policy which explains how we treat your personal data when you use
our services. By using our services, you agree that the GCO can collect and process your personal information in accordance with the privacy policy
of the UERMMMCI. Thank you.
IV. MEDICAL AND MENTAL HEALTH INFORMATION
Are you currently being treated by a physician for any medical conditions? [ * ] No [ ] Yes
If yes, for what medical condition are you being treated? ___________________________________________
Are you currently taking prescription or over-the-counter medication?? [ * ] No [ ] Yes
If yes, specify: ___________________________________________________________________________
Have you received counseling or psychotherapy in the past? [ * ] No [ ] Yes
If yes, when and why did you come for assistance? _______________________________________________
Jose Marlon J. Ponce
Person to be contacted in case of accident or serious illness: _______________________________________
Address: #6______________________________
F.Antonio Street Brgy. Salapan San Juan City Relationship: ______________
Father Contact Number: __________
09454958511

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V. Counselor’s Note:
st nd rd th
Areas 1 Year 2 Year 3 Year 4 Year
Academic

Career

Personal/
Social

Others:

Guidance and Counseling Office

G/F Administration Building
Office Hours: Monday to Friday (8:00 AM-5:00 PM)
Contact No: 8715-0861 to 77 loc.395
guidanceoffice@uerm.edu.ph