Student Information Sheet | Readability Center

Student Profile

Basic information about the learner.

Name of child (Pangalan ng bata)

Nickname (Palayaw)

Date of birth (Petsa ng kapanganakan)

Age, __ years and __ month/s (Edad, __ taon at __ buwan)

Name of school (Pangalan ng paaralan)

Grade level (Baitang)

Parent / Guardian Details

Information for both parents or guardians.

Father's name (Pangalan ng tatay)

Father's occupation (Trabaho ng tatay)

Father's email address (Email address ng tatay)

Father's mobile number (Mobile number ng tatay)

Mother's name (Pangalan ng nanay)

Mother's occupation (Trabaho ng nanay)

Mother's email address (Email address ng nanay)

Mother's mobile number (Mobile number ng nanay)

Home & Family Background

Daily environment details.

Home address of the child (Tirahan ng bata)

Number of siblings (Bilang ng magkakapatid)

Language/s spoken at home (Wika sa bahay)

Observed difficulties at home (Mga hirap sa bahay)

Reported difficulties at school (Mga hirap sa paaralan)

Are there family members who have learning difficulties? (May kamaganak ba na nahihirapan sa pagkatuto?)

Yes (Oo)

No (Hindi)

Learning Support & Medical History

Services and evaluations that support the learner.

Is the child enrolled in a tutorial program? (Naka-enroll ba sa tutorial?)

Yes (Oo)

No (Hindi)

Name of doctor who evaluated the child (Pangalan ng doktor)

When was the last evaluation by the doctor? (Kailan ang huling pagsusuri?)

Is the report available? (May report?)

Yes (Oo)

No (Hindi)

What is the clinical impression? (Clinical impression ng doktor)

Vision tested? (Nasuri na ba ang paningin?)

Yes (Oo)

No (Hindi)

Hearing tested? (Nasuri na ba ang pandinig?)

Yes

No

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Learning Attitude & Referral

Tell us about the learner's motivation and how you found us.

What is the child's general attitude towards school and learning? (Pakikitungo sa pagkatuto)

Name of person who filled out the form, Date (Pangalan ng sumagot, Petsa)

Person who recommended Readability Center (Nagrekuminda sa amin)