Grade and Section: _________________

Name: _________________________________________________

HOME LEARNING SPACE

PICTURE OF HOME LEARNING SPACE

MY HOME LEARNING SPACE

MY HOME
_______________________________________________ LEARNING
_______________________________________________ SPACE

_______________________________________________  Describe your

_______________________________________________ Home Learning
Space
_______________________________________________  Who help you
_______________________________________________ make your home
learning space?
_______________________________________________  What is your
_______________________________________________ favorite part of
your Home
_______________________________________________ Learning Space?
_______________________________________________ 
_______________________________
 HOME LEARNING SPACE
INVENTORY / CHECKLIST
UNIT ITEM
YES NO
LEARNING TABLE
MINI LIBRARY CABINET
FURNITURES
LEARNING MATERIAL ORGANIZER / BOX

PAD PAPER
PENCIL
CALCULATOR
COLORING MATERIALS (Crayons, Water
LEARNING
color, etc.)
MATERIAL
BOND PAPER
NOTEBOOK
ERASER

BOOKS
SUPPLIMENTAR MAGAZINE / NEWSPAPER
Y LEARNING DICTIONARY
RESOURCES BROCHURE / HANDOUTS

LAPTOP / SMART PHONE

ONLINE
PRINTER
LEARNING
INTERNET CONNECTION
RESOURCES

Prepared by:
_____________________________
(Name and Signature)

Grade ____: _____________

Parent’s / Guardian Name:

____________________________
(Name and Signature)

HOME ADDRESS:
______________________________________________________________________________________________

_____________________________________________________________________________
A. HOME LEARNING SCHEDULE

PERSONAL DAILY SCHEDULE

B. WELLNESS DAILY ROUTINE

 SELF ASSESSMENT ON PROPER HYGIENE PRACTICES CHECKLIST

NAME: ______________________________
GRADE and SECTION: _________________
DATE: _____________________
 WEEKLY MEAL PLAN

NAME: ______________________________
GRADE and SECTION: _________________
DATE: _____________________

PLAN FOR
WEEK BREAKFAST SNACK LUNCH SNACK DINNER IMPROVEMENT

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

SUNDAY

C. HEALTH SELF-ASSESSMENT
 STUDENTS HEALTH PROFILE
STUDENT BASIC INFORMATION
LAST NAME
FIRST NAME
MIDDLE NAME
SUFFIX
BIRTHDAY GENDER MALE FEMALE
CONTACT NO. E-MAIL ADDRESS
GRADE SECTION
STUDENT CURRENT RESIDENCE
BLDG. /HOUSE NO.
STREET BARANGAY
CITY/MUNICIPALITY PROVINCE
STUDENT MEDICAL HISTORY
With exposer to NO F YES Date of Exposer: _______________
COVID PATIENT
Does your family have any medical NO YES
history?
ALLERGY WITH COMORBIDITY
NO ALLERGY DRUG HYPERTENSION
OTHER TYPE FOOD ______________ HEART DISEASE
INSECT ____________ KIDNEY DISEASE
LATEX DIABETES MELLITUS
MOLD BRONCHIAL ASTHMA
PET CANCER
POLLEN OTHER/S ___________________

SPECIAL NEEDS
SPED
VISUAL IMPAIRMENT DIFFICULTY IN HEARING
DIFFICULTY IN MOBILITY LEARNING DIFFICULTY
DIFFICULTY IN DISPLAYING INTER-PERSONAL BEHAVIOR

STUDENT INTEREST

STRENGTH WEAKNESS

SKILL/S HOBBY

Physical Activity Readiness Questionnaire (PAR-Q)

Let us assess if you are ready to participate or engage in any physical activities by answering
honestly the Physical Activity Readiness Questionnaire (PAR-Q). Please accomplish the form
below by putting a check mark for every question.
Questions Yes No
Has your doctor ever said that you have a heart condition and that you should only
perform physical activity recommended by a doctor?
Do you feel pain in your chest when you perform physical activity?
In the past month, have you had chest pain when you were not performing any
physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your
physical activity?
Is your doctor currently prescribing any medication for your blood pressure or for a
heart condition?
Do you know of any other reason why you should not engage in physical activity?

If you have answered “Yes” to one or more of the above questions, consult your physician
before engaging in physical activity. Tell your physician which questions you answered “Yes”
to.
Source: National Academy of Sports Science. (2020). Physical Activity Readiness Questionnaire.
Retrieved from https://www.nasm.org/docs/default-source/PDF/nasm_par-q-(pdf-21k).pdf

BODY MASS INDEX

BMI is interpreted differently for people under age 20. While the same formula is used to
determine BMI for all age groups, the implications for children and adolescents can vary
depending on age and gender. The amount of body fat changes with age. It’s also different in
young boys and girls. Girls usually acquire a higher amount of body fat and develop it earlier than
boys.
The following table shows the percentile range for each weight status:
Percentile Weight Status
Below 5th Underweight
th
5th to 85 Normal or healthy weight
85th to 95th Overweight
95th and above Obese
Source: https://www.das.nh.gov/wellness/docs/percieved%20stress%20scale.pdf
NAME:

GRADE and SECTION:

My Perceived Stress Level:

MY PERSONAL PLAN TO
REDUCE STRESS