INFORMATION SHEET

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Your Psychologist will give some psychological tests. This will be used in connection
with them. Everything you write will be kept confidential. Please answer all questions
frankly and completely.

A. PERSONAL INFORMATION

Rank/Name: ___________________________________________ Date of Birth: _________________

Age: ____ Address: ____________________________________________________________________
How long in this address: ___________ Present Unit Assignment: ___________________________
Citizenship: ______________ Civil Status: _____________ Religion: ______________ Sex: ________
Number of Sisters: _________________________ Number of Brothers: ________________________
Father’s Name: ___________________________________ Occupation: _______________________
Mother’s Name: __________________________________ Occupation: _______________________
Spouse’s Name: __________________________________ Occupation: _______________________
Number of Children: ____________
NAME AGE NAME AGE

B. YOUR EDUCATION
SCHOOL/COLLEGES ATTENDED NAME OF SCHOOL INCLUSIVE DATES
PRIMARY
SECONDARY
_______________________________ ________________________
VOCATIONAL
COURSE: ______________________ Year Graduated: _______
_______________________________ ________________________
COLLEGE
COURSE: ______________________ Year Graduated: _______
_______________________________ ________________________
POST GRADUATE
COURSE: ______________________ Year Graduated: _______

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 ELIGIBILITY/S RATING DATE OF EXAM PLACE OF EXAM

EXTRACURRICULAR ACTIVITIES YOU HAVE BEEN ACTIVE

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ACHIEVEMENTS IN SCHOOL
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C. YOUR INTEREST AND TRAITS

1. What are your present hobbies and interests?

2. Clubs/organizational affiliates.

3. For what activities do you think you can earn extra income other than your salary?

4. Do you participate in sports?

5. What do you enjoy more than anything else?

6. List down your prominent traits and attitudes

YOUR STRENGTHS (Mabuting Ugali) YOUR WEAKNESSES (Kahinaan/Di Magandang Ugali)
a. ____________________________ a. ________________________________________
b. ____________________________ b. ________________________________________
c. ____________________________ c. ________________________________________

D. YOUR HEALTHS
HEIGHT: _______ WEIGHT: _______ PHYSICAL CONDITION: a)Good __ b) Fair __ c) Poor __
Have you ever been confine or treated Have you ever experienced the following? (Kindly check)
because of mental or emotional problem? ___ Insomia ___ Seizure ___ uncontrolled
________ YES __________ NO ___ Depression ___ Mood swings anger or
If Yes, kindly elaborate ___________________ ___ Anxiety ___ Poor concentration aggression
_________________________________________ ___ Irritability ___ Loss of consciousness
Did you ever take prohibited drugs? Do you drink alcoholic beverages? ____ YES ___ NO
________ YES __________ NO If Yes, how often in a week? ____________________________________________
If Yes, specify ____________________________ How much quantity per bout?
_________________________________________ ___ 1-2 bottles ___ 3-5 bottles ___ more than 5 bottles
When was your last Neuro-Psychiatric (NP) Have you ever been refused employment due to poor health?
Examination? ____________________________ ___ YES ___ NO If so, explain _____________________________________
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publication are STRICTLY PROHIBITED.
E. FAMILY MEDICAL HISTORY
Illnesses suffered by members of your family (mention the illness and specify the person affected):
__________________________________________ __________________________________________
__________________________________________ __________________________________________
Any Relative with Nervous Breakdown and Mental Illness? Answer: YES or NO on each blank:
_______ Father _______ Mother _______ Uncle _______ Aunt _______ Brother
_______ Sister ._______ Cousin (s) _______ Other family members

F. OCCUPATION (Work Experiences)

How many years have you been working: _________
Present Occupation: ______________________
How many positions? _____________________________
List down your present and past jobs
Job Position Date Salary Reasons for Leaving
_____________________________ ____________ ________________ __________________________
_____________________________ ____________ ________________ __________________________
_____________________________ ____________ ________________ __________________________
Which work do you like best? _____________________ Why? _______________________________________

Write a short analysis of yourself specially oriented towards the question “WHO AM I”. It
must include your impression about your personality and intelligence. Also, describe the event
that gave you great joy as well as your disappointments.

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I hereby certify that the above information are true and correct.

_______________________________ ______________________
Signature over Printed Name Date
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publication are STRICTLY PROHIBITED.
NAME: _______________________________________________ DATE: _____________________
HAND TEST
Write down two things each of these hands might be doing. Make your answer clear and
complete so that we know exactly what is happening.
(Sumulat ng dalawang bagay na maaaring ginagawa ng bawat isang kamay. Gawing
maliwanag at kompleto ang inyong mga sagot upang maunawaan naming mabuti kung
ano ang nangyari.)

CARD RESPONSES SCORES

I 1.

2.

II 1.

2.

III 1.

2.

IV 1.

2.

V 1.

2.

VI 1.

2.

VII 1.

2.

VIII 1.

2.

IX 1.

2.

X Mag-isip ka ng 1.
kamay sa iyong
imahinasyon at
isulat kung ano
ang ginagawa
2.
nito
Disclaimer: This document is part of the PPE (Neuro Exam) Preparation facebook group page file. Any forms of reproduction and
publication are STRICTLY PROHIBITED.
NAME: _______________________________________ AGE: _____ SEX: ________ DATE: ______________
CIVIL STATUS: _________________________________ OCCUPATION: _____________________________
ADDRESS: _________________________________________________________________________________
Instruction: Please rate each of the following items in terms of how characteristic they are of
you. Use the following scale for answering these items. (Lagyan ng itim ( ) ang angkop na
bilang/numero base sa iyong katangian o pag-uugali.)

1 2 3 4 5
Extremely Somewhat Neither Somewhat
Extremely
uncharacteristic uncharacteristic characteristic of characteristic of
characteristic of
of me of me me me
me
(Hinding-hindi (Maaaring Hindi (Maaaring Ako o (Maaaring Ako
(Ito Talaga Ako)
Ako Ito) Ako Ito) Hindi Ako Ito) Ito)

1 2 3 4 5
1. Once in a while I can’t control the urge to strike another person. (May mga
pagkakataon na hindi ko mapigilan ang sarili ko na makapanakit ng tao).
О О О О О
2. Given enough provocation, I may hit another person. (Kapag ako ay nabigyan ng
sapat na dahilan, maaari akong makapanakit ng ibang tao).
О О О О О
3. If somabody hits me, I hit back. (Kapag may nanakit sa akin, gaganti ako). О О О О О
4. I get into fights a little more than the average person. (Kumpara sa ibang tao mas
madalas akong mapasali sa mga away o gulo).
О О О О О
5. If I have to resort to violence to protect my rights, I will. (Kung kinakailangan kong
gumamit ng karahasan upang proteksyonan o alagaan ang aking karapatan, О О О О О
gagawin ko).
6. There are people who pushed me so far that we came to blows. (May mga taong
nagtutulak sa aking sarili para makipag-away).
О О О О О
7. I can’t think of no good reason for ever hitting a person. (Wala akong maisip na
mabuting dahilan upang makapanakit ng ibang tao).
О О О О О
8. I have threatened people I know. (May pinagbantaan na akong tao). О О О О О
9. I have become so mad that I have broken things. (Nagawa ko ng manira ng
gamit dahil sa sobrang galit).
О О О О О
10. I tell my friends openly when I disagree with them. (Sinasabi ko sa mga kaibigan ko
kung ako ay hindi sumasang-ayon sa kanila).
О О О О О
11. I often find myself disagreeing with people. (Madalas akong hindi sumang-ayon
sa ibang tao).
О О О О О
12. When people annoy me, I may tell them what I think of them. (Kapag ako ay
naiinis sa isang tao sinasabi ko sa kanya kung ano man ang naiisip ko sa kanya).
О О О О О
13. I can’t help getting into arguments when people disagree with me. (Hindi ko
maiwasang pumasok sa isang pagtatalo kung hindi sumasang-ayon sa akin ang О О О О О
ibang tao).
14. My friends say that I’m somewhat argumentative. (Ayon sa aking mga kaibigan
ako ay mahilig makipagtalo).
О О О О О
15. I flare-up quickly but get over it quickly. (Madaling mag-init ang ulo ko ngunit
mabilis din itong nawawala).
О О О О О
16. When frustrated, I let my irritation show. (Sa pagkabigo, ipinapakita ko ang aking
pagkainis).
О О О О О
17. I sometimes feel like a powder keg ready to explode. (Minsan pakiramdam ko ako
ay isang bomba na handang sumabog anumang oras).
О О О О О
18. I am an over-tempered person. (Ako ay isang mapagtimping tao). О О О О О
19. Some of my friends think I’m a hothead. (Ilan sa mga kaibigan ko ang nagsasabi
mainitin ang ulo ko).
О О О О О

Disclaimer: This document is part of the PPE (Neuro Exam) Preparation facebook group page file. Any forms of reproduction and
publication are STRICTLY PROHIBITED.
20. Sometimes I fly off the handle for no good reason. (Madalas akong magpakita ng
galit ng walang sapat na rason).
О О О О О
21. I have trouble controlling my temper. (Mahirap para sa akin ang pigilin ang galit
ko).
О О О О О
22. I am sometimes eaten up with jealousy. (Minsan nakakaramdam ako ng sobrang
pagka-inggit).
О О О О О
23. At times I feel I have gotten a raw deal out of life. (May mga pagkakataon na
pakiramdam ko na palagi akong nalalamangan sa buhay).
О О О О О
24. Other people always seem to get the breaks. (Lagi na lamang ibang tao ann
nabibigyan ng pagkakataon).
О О О О О
25. I wonder why sometimes I feel so bitter about things. (Nagtataka ako kung bakit
minsan nakakaramdam ako ng hindi normal sa mga bagay-bagay).
О О О О О
26. I know that “friends” talk about me behind my back. (Alam ko kapag pinag-
uusapan ako ng aking mga kaibigan).
О О О О О
27. I am suspicious of overly friendly strangers. (Duda ako sa ibang tao na masyadong
palakaibigan).
О О О О О
28. I sometimes feel that people are laughing at me behind my back. (Minsan
pakiramdam ko pinagtatawanan ako ng mga tao kapag ako ay nakatalikod).
О О О О О
29. When people are especially nice, I wonder what they want. (Kapag masyadong
mabait sa akin ang isang tao iniisip ko kung ano ang kailangan niya sa akin).
О О О О О

Disclaimer: This document is part of the PPE (Neuro Exam) Preparation facebook group page file. Any forms of reproduction and
publication are STRICTLY PROHIBITED.
Name: ______________________________________Age: _____ Date: ________________

Instruction: Kindly complete the following sentences as rapidly as possible.

Try to express your real feelings and opinion.

1. My work ________________________________________________________.
2. The future ______________________________________________________.
3. I want to know __________________________________________________.
4. Our family ______________________________________________________.
5. I feel ___________________________________________________________.
6. The training _____________________________________________________.
7. Much of the time _______________________________________________.
8. Money often ____________________________________________________.
9. If I could do anything, ___________________________________________.
10. Working _________________________________________________________.
11. I suffer ___________________________________________________________.
12. Friends __________________________________________________________.
13. My mother _______________________________________________________.
14. There are times ___________________________________________________.
15. Eating ___________________________________________________________.
16. My mind _________________________________________________________.
17. I sleep ___________________________________________________________.
18. My greatest longing ______________________________________________.
19. God _____________________________________________________________.
20. When I was a child, _______________________________________________.
21. Fighting _________________________________________________________.
22. Children _________________________________________________________.
23. My health _______________________________________________________.
24. I feel most proud of ______________________________________________.
25. Girls usually ______________________________________________________.
26. Death ___________________________________________________________.
27. My greatest ambition ____________________________________________.
28. I like best _______________________________________________________.
29. My habits _______________________________________________________.
30. I try to get ______________________________________________________.
31. Love in my life __________________________________________________.
32. I get pleasure from ______________________________________________.
33. My teachers ____________________________________________________.
34. I am sorry ______________________________________________________.
35. Back home ____________________________________________________.
36. I feel hurt _______________________________________________________.
37. Often I think ____________________________________________________.
38. I become embarrassed _________________________________________.
39. My head _______________________________________________________.
40. No one ________________________________________________________.
41. I am ashamed of _______________________________________________.
42. My education __________________________________________________.

Disclaimer: This document is part of the PPE (Neuro Exam) Preparation facebook group page file. Any forms of reproduction and
publication are STRICTLY PROHIBITED.
NAME: _______________________________________________ DATE: _____________________
DRAWING
Instruction:

A. Draw a man and write a short story in at least 5 sentences.

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Disclaimer: This document is part of the PPE (Neuro Exam) Preparation facebook group page file. Any forms of reproduction and
publication are STRICTLY PROHIBITED.
 B. Draw a woman and write a short story in at least 5 sentences.

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Disclaimer: This document is part of the PPE (Neuro Exam) Preparation facebook group page file. Any forms of reproduction and
publication are STRICTLY PROHIBITED.