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Membership in Organization

In School:
Name of Organization Position/Title
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Name of Organization Position/Title


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Attendance Record
Grade 5 Grade 6 Grade 7 Grade 8 Grade 9 Grade 10
Days of School
Days Present
Days Absent
No. of times late

Unique Features:
Friends in School:_________________________________________________ Outside School:_______________________________
Special Interest:___________________________________________________Special Skills/Talents:__________________________
Hobbies/Recreational Activities:______________________________________Ambition/Goals:______________________________
Guiding Principle in Life/Motto:_________________________________________________________________________________
Characters that describe you best:_________________________________________________________________________________
Present concerns/Problems:_____________________________________________________________________________________
Present Fears:________________________________________________________________________________________________

Health
Disabilities/Impairments:_____________________________________________ Chronic Illness:_____________________________
Medicines Taken Regularly:___________________________________________Vitamins Taken Regularly:____________________
Accidents Experienced/Effect:___________________________________________________________________________________
Operations Experienced/Effect:__________________________________________________________________________________
Check (√ ) immunizations you have had
______ Chicken Fox ______ Influenza ______ Hepatitis B
______Mumps ______ Measles(MMR) ______ Others( Pls. Specify):__________________________
______Booster ______Small Fox

Test Result
Nature of Test Result/Grade Year Taken
Intelligence Test
Subtest Result Subtest Result Year Taken
Achievement Test
NAT
NCAE
Diagnostic Test
Interest Test

CASE
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ACTION TAKEN
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FINDINGS/SUMMARY
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RECOMMENDATION
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