Republic of the Philippines

POLYTECHNIC UNIVERSITY OF THE PHILIPPINES

Office of the Counselling and Psychological Services
GUIDANCE AND COUNSELLING SERVICES

INDIVIDUAL INVENTORY RECORD FORM

I. PERSONAL INFORMATION

Francess Jewel M. De Guzman

Name: _________________________________ Nick name: _____________________
Jewel Sex: ________
Female Age: _______
19
Gender: (optional, please put a check) __ Lesbian __ Gay __ Bisexual __ Transgender __ Questioning __ Intersex
Year/Section: _________________
1-1 deguzmanfjm21@gmail.com Cell No.: _________________
E-mail Address: ___________________________ 09287554049 /
Date of Birth: _________________
November 21, 2002 Place of Birth: ____________________________
Pasig City Religion: _________________
Christian
City Address: __________________________________
29 Champaca st., De Castro subd., Provincial Address: ________________________________
B25 L66 Bulacan Meadows subd., Caypombo,
Sta.Lucia, Pasig City Sta. Maria, Bulacan
Apple Joyce Casayuran
Person to be contacted in case of emergency: ________________________________________________________
Address:B25 L66 Bulacan Meadows subd.,
____________________
Caypombo, Sta. Maria, Bulacan
Relationship: ________________________
Sibling 0946-4191493
Contact No.: ____________________
Boarding House/ Dorm Address: ____________________________________ Contact No.: _____________________

II. EDUCATIONAL BACKGROUND

LEVEL NAME OF SCHOOL LOCATION YEAR AWARDS

GRADUATED RECEIVED
Elementary Everlasting St., De Castro
De Castro Elementary School 2014 - 2015
Subd., Sta. Lucia, Pasig
City
Junior HS Road to M.Sapa, Brgy. With Honor
Mystical Rose School of Perfect Attendance
Caypombo Sta.Maria, 2018 - 2019
Bulacan, Inc. Ranker in various Academic Contests
Bulacan Consecutive Honor Student
Senior HS Dr. Teofilo Santiago Conduct Awardee
Sacred Heart Academy of 2020 - 2021
St., Poblacion, Sta, Perfect Attendance
Santa Maria, Bulacan Inc. Honor Student
Maria, Bulacan 3022
Others:

Nature of Schooling: _____ Continuous _____ Interrupted, why? ________________________

III. EDUCATIONAL BACKGROUND

Parents’ Relationship Status: (pls. put a check)

__ Married and living together __ Not married but living together

__ Married but separated/ annulled __ Father/Mother with another partner
__ Father/Mother working abroad __ Deceased, pls. Specify _______________

Father Mother

Name: ________________________________ __________________________________

Sarah T. Martinez
Educational Attainment: __________________ __________________________________
Elementary
Occupation: ____________________________ __________________________________
Housewife
Company:______________________________ __________________________________
N/A
Contact Number/s:_______________________ __________________________________
0061457265128

Parents’ Total Monthly Income: (pls. put a check)

__ Below – P5,000 __ P15,001-P20,000 __ P20,0001-P35,000 __ P45,0001-P50,000

__ P5,001-P10,000 __P20,001-P25,000 __ P35,0001-P40,000 __ Above P50,000

__ P10,001-P15,000 __ P25,0001-P30,000 __ P40,001-P45,000 __Other’s (pls. specify)

 1 No. of Brother’s: _____
Number of Children in the family: _____ 1 No. of Sister’s: _____
1

Ordinal Position in the family. (pls put a check) __ Eldest __ Middle __Youngest __Only Child

Who finances your schooling? __ Parents __Spouse __Relatives

__Brother/Sister __Scholarship __Others: _______

Nature of Residence while attending school: (pls. put a check)

__ Family Home __ House of married brother/sister

__ Relative’s House __ Rented Apartment

__ Boarding House/Dorm __Others: _____________

IV. HEALTH

A. Physical

I have problem/s with: (please put a check)

__ Vision __ Speech

__ Hearing __ General Health

__ Mobility/Physical Disability __ Others: _____________

Medicine and vitamins regularly taken: ____________________ Asthma

Chronic Illness: _____________________

Accidents experienced: ________________________ Operation experienced: _______________________|_

B. Psychological
Previous Consultation:

PROFESSIONAL YES NO WHEN? REASON

Psychiatrist

Psychologist

Counselor

Others:

V. TEST RECORD

DATE TYPE OF TEST RS PR DESCRIPTION

I have been informed that the data from this record will only be used for counselling and research purposes.
Furthermore, I have been assured that my record will be kept confidential and will not be released without my consent
except as required by law.

__________________________________
Signature/Date