Republic of the Philippines

CAVITE STATE UNIVERSITY

Imus Campus
Cavite Civic Center, Palico IV, City of Imus, Cavite 1x1
 (046) 471-66-07 / (046) 471-67-70 ID Picture
GUIDANCE AND COUNSELING OFFICE
Student Profile Form for Inventory
FULL NAME:
_______________________________________________________________________________________________________
Last Name First Name Middle Name
Permanent Address: ______________________________________________________________________________________
Current Address: _________________________________________________________________________________________
(if current address is not the same with permanent address)
Contact number: ________________________________________ Email Address: ____________________________________
Sex: Male Female Age: _______ Date of Birth: ____________________ Place of Birth: ___________________
Nationality: _________________________________ Religion: _______________________________________________
Civil Status:  Single  Married, name of spouse:
_________________________________________________________

Course and Year: __________________________ student number: _________________________________

Semester and School Year you first enrolled in CvSU: __________________________________________________

FAMILY BACKGROUND
Father Mother Guardian
Specify relationship_____________________

Full Name: ________________________ ______________________ _____________________________

Contact no: ________________________ ______________________ _____________________________
Occupation: ________________________ _______________________ ______________________________
Number of Sibling/s: ______ Birth Order: Eldest Second Middle Youngest Only Child

Estimated Monthly Family Income: (Please tick the appropriate box)

below -10,000 11,000 – 20,000 21,000 – 30,000 31,000 – 40,000 41,000– 50,000 above 50,000

EDUCATIONAL BACKGROUND
Name of School Address Year Graduated
Elementary _____________________________ ___________________________ ______________
Secondary/SHS _____________________________ ___________________________ ______________
Course taken
For transferees: _____________________________ ___________________________ ______________

CAREER EXPLORATION INFORMATION

What factors have influenced you most in choosing your course? Check [] at least three.
 Financial Security after graduation  Parents Decision/Choice  Opportunity to help others/society
Childhood Dream  Status Recognition  Challenge/Adventure
 Leisure/Enjoyment  Independence  Location of School
 Pursuit of Knowledge  Moral Fulfilment  Peer Influence
 Other reason/s: __________________________________________________________________________________
Current Career Concerns: (Please put a check [] on the current career concerns that you may be experiencing or wished to
be addressed in the future. You may check more than one option)
___I need more information about my personal traits, interests, skills, and values
___I need more information about certain course/s and occupation/s, specifically:_____________________________
___I have difficulty making a career decision/goal-setting
___I have many goals that conflict with each other
___My parents have different goals for me
___I think I am not capable of anything
___I know what I want, but someone else thinks I should do something else
___I don’t know and I am not sure what to do after graduation
___Others: ____________________________________________________________________________________

MEDICAL HISTORY INFORMATION

List any medications you are taking: _____________________________________________________  No, I don’t take
Do you have any of the following? Kindly put a check ()
 Asthma  Hypertension  Diabetes  Insomnia  Vertigo
Other medical condition, please specify: ______________________________________________________________
Allergy - specifically, allergic to: _____________________________________________________________________
Scoliosis or physical condition, specify: _______________________________________________________________
 None, I don’t have any medical conditions

Have you ever seriously considered or attempted suicide?  No Yes, Why: _________________________________
Have you ever had a problem with?
 Alcohol/Substance Abuse
 Eating Disorder
 Depression
Aggression
 Others: _______________________________________________________
Have any member of your immediate family member had a problem with:
 Alcohol/Substance Abuse
 Eating Disorder
 Depression
Aggression
 Others: _______________________________________________________

Do you engage in physical fitness activity?  No  Yes, Specify: ___________________________________________

If yes, How often:  Everyday
 2-3 times a week
 2-3 times a month
How would you rate your current level of stress, 10 as highest & 1 as lowest:
 Low (1-3)
 Average (4-7)
 High (8-10)

I hereby attest that all information stated above is true and correct. ______________________________
Signature over printed name