Republic of the Philippines

DEPARTMENT OF EDUCATION
Region III – Central Luzon
Schools Division of Zambales
Iba District
LITTLE BAGUIO ELEMENTARY SCHOOL - 106877
Purok 2, Bangantalinga, Iba, Zambales 2201

ANECDOTAL RECORD

Name: _______________________________ Date of Birth: _____________________

Applies
Statement Doesn't Apply Somewhat Certainly Apply
1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
Very restless, open running or jumping up and down hardly
ever still
Through want from school
Squirmy, pigsty child
Open destroys owned or others belongingness
Frequently fights with other children
Not much liked by other children
Often- worried, worries about many things
Tends to do things on his own rather solitaire
Irritable – is quick to fly off the handle
Often appears miserable, unhappy, and tearful or distress
Has twitches, mannerism, or ticks of the face or body
Frequently sucks thumbs or finger
Tends to be absent from school for trivial reasons
Is often disobedient
Has poor concentration
Tends to fearful or afraid of new things or new situations
Fussy or over particular child
Often tells lies
Has stolen things in one or more occasions
Has wet or soiled self at school this year
Often complains of pains or aches
Has hard cheers on arrival at school or has refused to come
into the room or building this year
Has a stutter or stammer
Has other speech difficulties
Bullies other children

________________________________ _______________________________
Signature of Student Signature of Parent