PUPIL PERSONAL DATA FORM

Republic of the Philippines

DEPARTMENT OF EDUCATION
Region IV-A
Division of Batangas
DISTRICT OF _______________________

Name: _____________________________________________________________ School_____________________________________________________________

(Surname) (Given Name) (Middle Name)

Sex__________ Place of Birth __________________________________________________ Date of Birth ____________________ __________________________

(Barangay) (Town) (Province) (Date of Entrance)

II. FAMILY DATA

Educ’l Living/ Death
NAME OF PARENT/GUARDIAN Date of Birth Place of Birth Attainment Religion Occupation Business Address Dead Date/Cause

No. of Children in the family: Older Children: Younger Children:

Boys ________________ Boys _______________ Boys _____________
Girls ________________ Girls _______________ Girls _____________
Total ________________ Total _______________ Total _____________
LANGUAGE USED AT HOME: ______________________________________
OTHER LANGUAGES SPOKEN: _______________________________________

III. ELEM. SCHOOL STANDARD TEST RECORD

GRADE AGE PERCENTAGE
TEST FORM DATE SCORE EQUIVALENT EQUIVALENT FILE RANK C.A. M.A. I.Q.
IV. WITHDRAWAL RECORD VI. RE-ENTRY RECORD
Date Cause Transferred to Date Cause Received from

CODE USED: IV 1. Transferred 6. Home Chores V. 1. Transferred from another school

2. Employment 7. School Atmosphere 2. Loss of job
3. Poor Health 8. Financial Difficulty 3. Health regained
4. Marriage 9. Death 4. Desire for additional schooling
5. Poor Scholarship 10. Distance of home 5. Permission by school authorities
IMMUNIZATION AND IMMUNITY TEST DISEASE EXPERIENCE
VI. HEALTH EXAMINATION/INSPECTION Date Result Date Result Date Result Disease Inclusive Disease Inclusive
Date Date
School Allergy Test Allergy Mumps
Grade BCG Chicken Pox Parasitism
Date CDT Diphtheria Rheumatism
Age Diphtheria Chronic Tonsillitis
Height Pertussis Cough Typhoid
Weight Small Pox Dysentery Fever
Vision Tetanus Malaria Whooping
Hearing Measles Cough
Flouroscopy Tuberculine Test Yaws
Circulatory System
Heart FIELD VISITS
Blood Pressure Dwelling Waste Home Reco- Teacher or
Nervous System Date Facilities Study Conditions Disposal projects mmendations Teacher-Nurse
Glands
Eyes and Ears
Nose, Mouth & Throat
Skin and Scalp
Orthopedics
Intestinal Parasitism
Other Diseases
CODE USED 1. Ears & Eyes 2. Nose, Mouth & Throat 3. Skin & Scalp Orthopedics Other Diseases Action Taken Field Visits
a. Granular eyelids a. Nasal obstruction a. Pediculosis a. Deformities (Indicate Diseases) R- referral
a. Flouroscopy b. Inflamed eyes b. Dirty teeth b. Tinea Flava b. Faulty posture T- treated E= Excellent
c. Squinting eyes c. Defective teeth and gums c. Scabies O- further G= Good
b. Flourography d. Defective throat d. Inflamed throat d. Ring worm observation F= Fair
e. Ulcers C- corrected N= Needs
f. Minor injuries Improvement