INDIVIDUAL RECORD FORM Name. a sex: Boy)f alt orave A sewoouacency sare examiner Me. Fakes ered ay PURPOSE OF TESTING “em Prtorence: ole one) Year Mon CGD ver HED doers 10 Te eg Preference: rie oe) Date itn | aOR Lert wixED ‘creonctosies Age an mee ‘Compote Battery: a enone noTon suTeaTs {Ruri Soesmonomy. 18 B13 iSite Gondiaion 3 Sten oa ‘088 NoroR courosire 5 Uppartine Coranaton 21 ‘ttt ona 2 ‘Upper socee SSE ” DIRECTIONS ‘SomleteBatery ‘oincilapronodt endtachetetendin BURRIS eton co meee RE Rr i Sal ee. Jrlccthiton iemranscsreoapantssve ven 1 Pollow Steps 1 and 2 Yor Comstete Battery, ex Seoleetie: Litera aie St ee ee oped cleat Siento eee AGS ruptured by Amero Gudenee Seren, ne, Cl Pies MN 5014[SUBTEST 1: Funsiag Spaed and Anity ‘SUBTEST 2: Balance 1. Staning on reer Lg on oo (10 socons manu That 1D ascetic [SED] © [re | [os Jaw 2 Sanding on Peter Leg on Balance Bsn (10 scandium pra) TALS SAM ames aL dL co A. vahing Foner on Wing Lino (steps maximum pra) [| « [os [as] « ‘ming Foyer on Blane Boom tr masinom or Wa lela] «|s> ori eto on Wiking Leste mec pe FEED. 3 mee m2. 6 wle[»| «|: “Laing FormardHeettoTs on lance Beem (8 stoe aimun sar na) vam TTT. eee ree ETE - 3 soe TeD| of sfele |. Stpsing Over Response S000 Sek on Balance Boom FEET te nihteninen nia Sherr em 2 Stoning on Potere Log on Batncn agm—Eyer Closed 10 cence mss pa a) a aa © © © © 8 6 OOSUBTEST 2: Biter! Coordination "toon Fei Atenaay Wh Making Crees ih Fingers” (50 seconds mann) a TESTI [ne sos rcesorsreerenroreesruseueceeeesel EGO} cm: eee cre mies “= EDO Ol osocrw aR amet n rae “| BION rie a RT a oo a aa =| BIG | O nesrseear eee orig CD] o| + | 29] 48 |v] on lun] SUBTEST 4: Svonaih é "sun ot ng apni ee gras lol s[efafelefelrfele[alnlalaluln le o “owen T"" (SE) © | 12] | oe| 04] o |e enfia ‘su knee Pups Fo: Boys Unser Ago 8 an Gi) 20 Soconc) ED] ©] v2] 6 o> [on] — | - foul — | fo] - for] | — fl Dara enopa Dore fae Oi Des TED] | =| -|~| ~ |e || - oufon| - ll - orl] - | @ O ©) @ ©) @ ® 5 @) ® © 5 arTiaAs one iatintone 3[SUBTEST 5: op0r-Limb Gooesinton "-Bomon«Ba nate Hw Be Hes) Blas “Toveng Nove wih nex Fingers Eyes Close (00 secon avian) "| ‘Touching Thumb te Fingerine Eves Clee 90 secon minum) ae 2. Pong Tum ong nex inge (80 secones maui) “TED to] re | a a = _ z 4 foe J JD J) ) © EaSUBTEST 7: Visua-#ot Cont "ing tra mt pre Hin {raving Line Tvough Sag Pah wi Prteroa Hon ‘mone eo 0 0 © © 6 6 9‘SUBTEST 8: Uoper-Limb Sood and Doxtey |. Pacing Penis m2 Box win retorts Han (15 econ) 2 Pacing Penns in To Boxe th Bot Hans 50 secon manu fr seven caret pas) (TET TT TT se secon: 15.28 ka 3. Soring Shape Carew Praferd Han (1 on) 4 steging Baste wih frotood Hand 5 6con) S.Dilacng Pope with Petened Hand (15 secon) rontoenor recs 6. oawing arta Lins wth Prot Mand (15 secon ‘oween or uns "ang stn ees th rts tn cr aia tein jaa Hand 5 secon ngroore SC aa ea) NOTES/OBSERVATIONS.