Chemistry Student Questionnaire

Name:______Date:______Period:______SLC:______Chemistry Student Questionnaire 1) What name do you want the teacher to use for you? ______Birthday:______2) How many people live with you? ______Who lives with you? (Circle all that apply): Mom Dad Stepmom Stepdad Grandma Grandpa Sisters Brothers Stepsisters Stepbrothers Friends Foster Parents Group Home Cousins Other:______3) Who is the closest person to you in your life? Name______Age:______Why did you choose this person? ______4) How can you be reached? Home Phone ______Cell Phone ______Email: ______5) How do you spend your time on the weekends and after school? (Circle all that apply): Babysitting Church Phone Television Job Computer Music Boyfriend/Girlfriend Reading Friends Homework Shopping Sports Travel Sleep Dance Pets Parties Family Exercise Video Games Art Movies Talking Internet IM/Email Inside Going Out Studying Eating Writing Outside SkatingOther:______6) Favorites: TV Show:______Food:______Movie:______Candy:______Band/Singer:______Activity:______Book:______Game:______

7) What have your grades mostly been in the past? A B C D F What is your GPA? ______8) What would you most like to do after you graduate? (Circle one) College/University Community College Work I don’t want to graduate 9) What is most important to you in your future? (Circle all that apply): Money family power marriage success pride happiness children grades love helping people religion friends fame college cars graduation Clothes community music/art peace change travel other:______10) Do you think you are good or bad in the following areas? (Circle good or bad for each) Writing (Good/Bad) Reading (Good/Bad) Spelling (Good/Bad) Behavior (Good/Bad) Math (Good/Bad) Art (Good/Bad) Music (Good/Bad) Sports (Good/Bad) 11) How would you describe yourself? (Circle one word in each pair): Organized/Disorganized Neat/Messy Loud/Quiet Nice/Mean Responsible/Irresponsible Healthy/Unhealthy Sad/Happy Confident/Shy Motivated/Lazy Energetic/Sleepy Smart/Dumb Friendly/Loner Stressed/Relaxed Crazy/Calm Polite/Impolite Leader/Follower Artistic/Not Artistic Bad/Good Funny/Not Funny Lucky/Unlucky Religious/ Not Religious Ugly/Attractive Skinny/Fat Talented/Untalented 12) At what age did you start speaking English? ______

13) Have you ever been in special education classes or school programs? Yes/No

Which ones? ______

14) Do you think you have any learning disabilities? Yes/No

If yes, why? ______

15) Do you consider yourself to be a good student? Yes/No

Why/why not? ______

16) Do you have a lot of absences or tardies? Yes/No

If yes, why? ______

17) Would you say that your education has been a success so far? Yes/No

Why/why not? ______

18) Do you like the SLC you have been assigned? Yes/No Why/why not? ______19) Please list five of the hardest books that you have finished in your life: 1) 2) 3) 4) 5)

Thank you for taking the time to fill out this questionnaire. I look forward to knowing you better this year 