MS- ELEMENTARY

Pupil___Lumawod Lorraine
D.__________________NICKNAME:___Lorraine_________
____________________________________________AGE:_____9______ SEX:____F___
Nationality __Filipino_____ Ethnic Affiliation:______________ Religion:
___Catholic____
Date of Birth: ___________ Place of Birth: ___________ Birth Registered
______Yes___
Drop Out History
__________________ No How long?_____________
Reasons:_____________________
Distance of School from home: ________________ Means of trans. To

ABSENTISM
Grade
Level AND DROPOUT
PROFILE
School
Year
Year Level
Nut.Status
No.of
Days Absent
Wt.
(kg)
Reasons
Remarks
Summer Dropout
Ht.(cm)
How long?
Immunization
BCGReasons:

DPT
Polio
Hepa
Whooping Cough
Chicken Fox
Measles
Illness Incurred during the
year
Major Accidents

school:________
Source of Financial Assistance: ____________ Yes ___________ No
Sources________
Students lives with:_____________ Person who helps child in

HEALTH AND NUTRITION PROFILE

Homework:____________
BACKGROUND PROFILE
Pupils
Information

FATH
ER

MOTH
ER

No. of Family Member

Dropout:______________
Parental
Status:____________________________
Member of Com.Dev.Org._______Yes
_______No
Mo.Household Income:_____________
_______
Appliances at Home:________________
________
_________________________________________
FAMILY DWELLING:

House/Lot Ownership:_______________ ________

Type of House:_____________________ ________
Type opf Toilet:____________________ _________
Source of Water Supply:______________ ________
Power Supply:_______________________________

EDUCATIONAL PROFILE
GRADE ONE

S.Y

GRADE THREE

GRADE FIVE

S.Y

S.Y

II

II

III

III

IVIV

VV

VI
VI