i=l neal Dos vy Date of Fest Western pace Record Form pias? [Chronological Age Part 2 (Supplemental) Le General Recording and Scoring Directions 1. Unless otherwise indicated, score 1 point fora correct response and 0 points for an incorrect response. 2. Write NRif the patient does not respond and score a5 0 3. Unless otherwise indicated, the maximum point value for each item isin parentheses in the lower right-hand corner of the score column, 4, Ifthe patient’ response is different from the target, wrlte it verbatim in the space provided. so cas-wwui-o-s @PsychCorp suena il llrightsreserved. Printed in the United States of America, ae 12345678910 2ABCOE slrau sates 010Reading A, Comprehension Materials: Stimulus Book of Sentences Directions: ‘Turn to the Trial Item on page 7 in the Stimulus Book, Point to the incomplete sentence and the word choices and say, Read this sentence and point tothe missing word, Choose the best word from these, Repeat the directions if the patient does not seem to understand, Ifthe patient does not give the correct response, point to the correct response {for this item only) and say, This is the missing word. The tree has..Jeaves. Let's try some ‘more, Present the test items. Scoring: Circle and score the patient's response. Correct responses are in bold type. See | tem sponse nee | ieee | 1 Therinis Blue . wet met sea em | 2 | 0 2 Asoldlercoriesa—__ gun B shoot fun 4. groceries ene | 2 | 0 Ti Sepa nd ds =e cine | Heisa_. mechanic ¢. bus em | 4 | 0 “4, Teachers return to school every al 2 leaves i, children | They teach © spring 4. books ene | 4 | oo 5. Shovels and saws ae common took ' farmer b, forest | They have parts made of . metal a ene | 6 ° | 6. Farmers often row wheat, com andother 2 coal b, wactors sans. They can also produce, © earth 4. vegetables ene | 6 | 0 7, Energy used tobe relatively plentiful. Due «a. boling water b, the banks to oll shortages, many nations are turning thesun 4. economy ene | 8 | o toaltemate sources suchas 8, The Ttanicwasan ocean ner thot wasthought | a lostpower ’, been badly damaged tobe unsinkablebutithitan iceberg andsonk | c. cated passengers. beengoingwest. ena | 8 | 0 ‘in 1912 killing more than a thousand people. Itwould not have sunk fit had not Comprehension of Sentences Score (ax = 0) 2 OH ReadingReading Commands ‘Materials: Stimulus Book, pencil Directions: Turn to page 16 in the Stimulus Book. Say, want you to read this aloud and then do what it says, Present each item in the order it appears in the Stimulus Book, Repetition: Repeat the directions ifthe patient completes only one part ofa two- ot three-part command or does not respond. Scoring: Score each item twice; once for reading and once for performance ofthe com- ‘mands, Score the maximum points (in parentheses) ifthe patient accurately reads the item aloud (deduct paraphasias) and/or correctly performs the command. Score only the part(s) ofthe command read accurately without paraphasias, and/or only the part(s) of the command performed accurately. Teatog | Peomance tem Sore Sere 1. Raise your hand. o o 2 Wave goodbye o o 4. Close your eyes. o o 4. Draw a ross wit your foot, @ 2 5. Point tothe chairand then othe dase 2 @ 6, Plckup the pencl knockthee times, and putt back, ® ® Reading Commands Score Determining Which Task to Administer Next Directions: Add the patient's scores from Reading tasks A and B, Ifthe Combined ‘Score is greater than or equal to (2) 50, discontinue the Reading tasks, (See page 15 in this Record Form or chapter 3 in the Examiner’s Manual for instructions on calcu- lating the patient's prorated Reading Total) Ifthe Combined Score is less than (<) 50, continue administration of Reading tasks C-I. ‘A. Comprehension of Sentences Score B. Reading Commands Score Combined Score Reading. Written Word-Object Choice Matching D. Written Word-Picture Choice Matching E, Picture-Written Word Choice Matching timulus Book, cup, comb, pencil, flower, matches, screwdriver Directions: Place the objects in a random orderin front of the patient. Tarn to page 22in the Stimulus Book. Say, Poin tothe object tat goes with this word, Present the resto the items, em Sore 1 cup H 2 comb 1 3. pencil 1 4 flower 1 ‘5, matches 1 6. screwdriver 1 ton Word-Objet Choice Matching Score [-]atn=9 ‘Materials: Stimulus Book Directions: Turn to pages 28 and 29 in the Stimulus Book. Direct the patient's attention to the two-page format by pointing to the word flower and saying, Point to the picture that ‘goes with this word, Present the rest of the items, em Kore 1. flower i 2_ matches 1 3. cup 1 4. screwdriver 1 5. comb 1 6. pencil 1 Written Word-Picture Choice Matching Score | tar= 9) ‘Materials: Stimulus Book Directions: Turn to pages 40 and 41 in the Stimulus Book and turn itso that both pages (the picture and words) face the patient, Point to the picture of the cup and say, Point to ‘the word that goes with ths picture. Present the rest of the items, em Score en pencil screwdriver matches lower ‘comb i 1 1 1 1 1 Picture-Written Word Choice Matching Score [___oim=@ F, Spoken Word-Written Materials: Stimulus Book Word Choice Matching Directions: Turn to page 52 in the Stimulus Book. Say, Show me the word flower. Present the rest ofthe items ‘Scoring: Circle the patient's response, Correct responses are in bold type. ten Response Sear 1. flower atover_bflower cree dpoweregarden€NR | 1 | 0 2. table avcable bfable table dichair e-cloth ane [1 | 0 3. purse money b.nanny _cwallet_ purse e.nurse A a 4 window [awillow _bwindow _«.glass door ewinter ENR | 1 | 0 4 A reading Spoken Word-Written Word Choice Matching Score [| har=4G. Letter Discrimination Materials: None Directions: Transfer the Auditory Word Recognition-Letters score (sum of ems 19-24) {rom Record Form Pact 1 (page 5) in the space below. Letter Discrimination Seore [___|idn=0) H, Spelled Word Recognition Materials: None Directions: Say, Tell ne what word | spel. the patient does not understand the task, give an example not listed on the test (eg, b-eis the word be), Present the test items, Sore hammer 1 1 1 bare 1 1 telephone 1 Spelid Word Recognition Seore [n= |. Spelling ‘Materials: None Directions: Present each ofthe following words orally and ask the patient to spell each word. Say, Spel the word up. Ifthe patient does not understand the task, give an example notlisted on the test (eg, Dogis spelled d-o-g). Present the test items, Tew up cat pond house pencil ReadingWriting ‘Materials: Stimulus Book, unlined paper, pen General Directions: Place a sheet of unlined paper and a pen (not a pencil) on the table in front of the patient. Say, Now I want you to write some different things. Use additional sheets of paper as necessary. After the patient finishes, using a sheet of paper, label it with the patient’s name and the date of testing. A. Writing Upon Request B. Writing Output C, Writing to Dictation uniting Directions: Say, Vite your name and address. The patient may print or write in cursive. Scoring: Score 1 point for each recognizable word or number (Maximum = 6 points). Deduct # point for each spelling mistake or paraphasic error. Writing Upon Request Score Wax = 6 Additional Materials: Stimulus Book, stopwatch or watch with second hand Directions: Turn to page 56 in the Stimulus Book Pienie Scene). Say, Write about what ishappening in tis picture or Write story about whatis going on inthis picture. the patient begins to list words or write incomplete sentences, say, Write in sentences, Move the picture toward the patient’ intact visual field if necessary. Encourage the patient to pay attention toall aspects of the picture, Time Limit; Allow up to three minutes fora response. Scoring: Score 34 points fora full description; 8 points for each complete sentence with 6 ‘words or more; I point for each correct word in incomplete or short sentences; and 1 point foreach isolated word up to a maximum of 10 points, Deduct ¥ point for each spelling or paraphasic error. Do not score punctuation, Writing Output Score Wor = 38) Directions: Say, Write the following sentence: “Pack my box with five dozen jugs of liquid detergent.” The sentence may be broken up and parts repeated once ifthe patient cannot remember it. Scoring: Score 10 points for the complete sentence or 1 point for each correct word, Deduct ¥ point for each spelling or paraphasic error, Writing to Dictation Score ax = 1) Determining Which Task to Administer Next Directions: Add the patient's scores from Writing tasks AC. If the Combined Score is greater than ot equal to 2) 40, discontinue the Writing tasks, (See page 15 in this Record Form or chapter 3 in the Examiner's Manual for instructions on. calculating the patient's prorated Writing Total, If the Combined Score is less than (<) 40, continue administration of Writing tasks D- AA. Writing Upon Request Score B.Wrlting Output Score —] c. wating to Dictation Score Combined ScoreWriting Dictated Words E, Alphabet and Numbers *. Dictated Letters and Numbers ‘Materials: (Lf needed for cueing) Cup, watch, hammer, telephone, screwdriver Directions: Say, \iite the following words, Dictate each word. Ifthe patient does not respond or appears to not understand, show the actual object and gesture to the patient to. write the object name, Ifthe patient writes an unrecognizable word or does not respond, spell the word verbally and gesture to the patient to write the object name. Scoring: Circle the appropriate score for each part of the task the patient performs cor- rectly. Ifthe patient is unable to write the correct response after cueing, circle 0, ‘sore Diet al tem Wort | object _| sptiog | inane 1 up 1 1 s o 2. watch 2 2 1 o 3. nose 1 1 isi o 4, hammer 2 2 1 o 5, telephone 2 2 1 o 6. screwdriver | 2 2 1 ° Writing Dictated Words Score Alphabet Directions: Say, Write the letters of the alphabet, Scoring: Score ¥s point for each letter written (maximum =12.5 points), even fit is out of order. Numbers Directions: Say, Write the nurbers 0 through 20. Scoring: Score point for each number written (maximum = 10 points), even ifitis out of order. Alphabet and Numbers Score Letters Directions: Say, Write these letters. Dictate the letters. Scoring: Score Ye point for each correct response and 0 points for each incorrect response. ew Sere 1 2. 3 4 5. Numbers Directions: Say, Write these numbers, Dictate the numbers, tem Sore eS 7.64 9.700 7 1 8.32 1 1 10, 1867 1 Dictated Letters and Numbers Score Wax =75) Writing S/G. Copying a Sentence Directions: ‘Tarn to page 57 of the Stimulus Book. Say, Copy this sentence, Move the Stimulus Book toward the patient's intact visual field ifnecessary. ‘Scoring: Score 1 point for each correct word (up to 10 points for the complete sentence). Subtract ¥ point for each incorrect letter. Copying a Sentence Score (Max = 1) Apraxia ‘Apraxia ‘Materials: Flower, matches, comb, toothbrush, spoon, hammer, key, sheet of unlined Paper, telephone Directions: Say, 'm going to ask you to do some things. Try todo them as well as you can. If the patient does not perform the action adequately or indicates that he or she cannot do it, demonstrate the action for him or her to imitate. If the patient does not imitate the action adequately, provide the object where applicable). Allow for variations in normal perfor- ‘mance (eg. punching telephone keys versus rotary dialing ofa telephone). Scoring: Circle the score that reflects the patient's performance of each task, Score Criteria '3= A good performance upon command (eg, patient whistles by pursing his or her lips and blowing to make a whistling sound: patient sniffs a flower by wrinkling his or her nose and inhaling through the nase) 2= An approximate performance upon command (e.g, patient "whistles" by pursing his or her lips and blowing without making a whistling sounes patient “sniffs” a flower without inhaling); ‘A good performance upon imitation (e.g, patient imitates a whistle by pursing lips and blowing to make a whistling sound; patient imitates sniffing a flower by wrinkling his or her nose and inhaling through the nose); Patient uses a body part as an object (eg, fingers used as a comb through the har). 11= An approximate performance on imitation (e.g, patlent imitates a whistle by pursing his or her lips and blowing without making a whistling sound; patient imitates sniffing a flower by grimacing or inhaling through the mouth); An adequate performance with the object (e.g, patient sniffs with the flower) (0 An incorrect or no response after imitation or with the object (e.g, patientimitates pursing lips, but does not blows; patlent rubs the flower on his or her nose, but does not inhale).ypeatResponse {Upon Command mitatedtitneeded) | withobec, ‘od =} pots Gead= 290s (reeded) em Aarne = 25 ope = Np ‘eit | treat Uppers 1. Make a fist, 3 2 2 1 ° 2, Salute, 3 a 2 1 ° 3, Wave good-bye. 3 2 2 1 ° 4, Scratch your head, 3 2 2 1 0 5, Snap your fingers. 3 2 2 1 0 Facial 6. Put out your tongue. 3 2 2 1 ° 7. Close your eyes. 3 2 2 1 ° 8, Whistle. 3 2 2 1 ° 9, Pretend to sniffa flower. 3 2 2 1 1 ° 10, Pretend to blow out amatch. 3 2 2 1 1 ° Instrumental 11, Pretend to use a comb. 3 2 2 1 1 ° 12, Pretend to sea toothbrush. 3 2 2 i 1 ° 13, Pretend to use a spoon to eat, 3 2 2 1 1 0 14, Pretend to use a hammer. 3 2 2 1 1 ° 15, Pretend touse a key. 3 2 2 1 1 ° Complex 16, Pretend to start and drive a car. 3 2 2 1 0 17, Pretend to knock at a door and openit. 3 2 2 1 0 18, Pretend to fold a sheet of paper. 3 2 B 1 1 a 19, Pretend to make a phone call, 3 a a 1 1 0 20, Protend to play the piano, 3 2 2 1 ° Apraxia Total Wax = 60) aprada/ 9Constructional, Visuospatial, and Calculation A. Drawing Materials: Directions: Place a piece of paper on the table with a pen (nota pencil) Say, row a_. Ifthe patient fails to draw a complete Figure, says this.as complete as you con make i? Ifthe patient does not respond or does not appear to understand, turn to page 58 in the Stimulus Book and present the picture tothe patient for 10 seconds. Remove the picture and repeat the item, Optional: Ifthe patient still does not respond or does not appear to understand, present the picture and leave it for the patient tocopy. ‘Time Limit: 30 seconds per item Scoring: Score the point value that best reflects the patient's drawing, Deduct 1 pointif patient needs to sce the visual stimulus. Deduct 2 points if the patient draws by copying. timulus Book, unlined paper, pen, stopwatch or clock with second hand om Serng Score 2points = Closed cle 1. Drawa circle, ‘point = Curved segment Opoints = Income figure ono response ‘points = Perspective and form are represented. Subtract 1 point foreach Inappropriate angle point = Allnine lines ae drawn, Opoints = Incorect figue orno response 2. Drawa cube, 2points = Closed square 3, Drawa square, ‘point = Fourlines points = Incorect figure orno response 1p not score the accuracy ofthe clock hands Spon cone ge rumes and seting Th hourhands shoe 4. Drawacock Setthahandeto ten ater aoven” | {Pats ~ Number orsatingarnat conc. [Remind the patient to set the hands to“ after 11" necessary) 2points lost numbers are absent, incorrect or poorly placed, ire only or very poor figure Inecognizable figure or no response 1 point points points = Qualty 2points = Symmetial ‘point = Asymmetrical Dpoints = Incorect figure orno response 5, Drawatree, Spoints =Complete perspective Subtract 1 point for lack of perspective. 6. Drawahouse, Subtract 1 point for mising deta 2points = Approximation ‘points =Incorect figure or no response Spoints = Completeness and symmety on Subtract 1 point foreach missing body part (e.g. arm, eg, head torso {point points 5 points 8, Place amark atthe middie/in the center ofthistine, | Pee Mt cy gor eration, (Point tothe line below) points ‘constructional, Visuospatial, and Calculation‘Materials: Stimulus Book, four Kos blocks, stopwatch or clock with a second hand Demonstration and Trial Item Directions: Place the four blocks on the table in front ofthe patient. Say, Look at these blocks. They are all alike. On some sides they areal ved, on some all white, and on some, half red and half white. Turn to page 64 in the Stimulus Book, Say, am going to put the blocks together to make them look like this picture, Watch me first, lowly arrange the blocks to match the design in the ‘Stimulus Book. Then mix up the blocks, Say, Now lookat the picture and make one just ike it with the blocks. Ifthe patient fails to replicate the picture in 90 seconds, mix up the blocks and have him or her try again, Test Items Directions: Present the tes items even ifthe patient fails to correctly replicate the Demonstration Item, Turn to page 65 in the Stimulus Book and say, Pus the blocks together to make them look like this picture, Allow the patient atleast 2 minutes before presenting the next item, Mix up the blocks after each item, Repetition: None. Allow the patient only one attempt per item. Scoring: Circle the point value that best reflects the patient's drawing, 3 points = Correct design within 60 seconds ‘tem | Sore 2 points = Correct design with extra time (up to two minutes) point = Four blocks put together, but design is incorrect Opoints = Four blocks not put together or no response 2 Block Design Score Wax = 9) C. Calculation ‘Materials: Stimulus Book Directions: ‘Turn to page 68 in the Stimulus Book. Point to the equation and say, | would like you to add, What is5 +42 The patient may respond orally or by pointing to the correct answer on the stimulus page. Present the rest ofthe items. Scoring: Circle the patient's response. Correct responses appear in bold type. item Response See would like you to add. Whatis 5447 1 5e4 a9 b.20 e146 en [2] 2.642 a4 bi es 43 enr | 2 | 0 3443 26 BD e7 a4 en [2] 0 would like you to subtract, Whatis 6 ~ 27 46-2 2.8 ba em 43 ene [20 5.907 216 bd cs d63ene | 2 | 0 68-3 a5, ba. om diene | 2] 0 would lke yout multiply. Whats 42? 7 Ax2 a7 ba es dé eNR [2] 0 8. 5x3 26 b2 8 wenn | 2 | 0 2. 6x7 a2 bat a2 d.25 enn | 2 | 0 Twould like you to divide, Whatis8+4? 10. +4 aR b2 em G4 en [2] 0 1. 6426 2B 6.56 es 472 ene | 21 0 12.1853 a4 b2t es ao Ham IN [2170 Calculation Score (ax = 29) Constructional, Visuospatial, and Calculation "D, Raven's Coloured Progressive Matrices Materials: Raven's Coloured Progressive Matrices (RCPM) Stimulus Book, stopwatch Directions: Open the RCPM Stimulus Book to Set A, Item Al, Point to the pattern and (RCPM) then the six pieces below it and say, Point to the piece that is missing, or say, Look at this pattern. Apiaceis missing tis one ofthese, Point to the piece that goes there. Present the Scoring: lecord the number corresponding tothe patient's response ot NRif the p does not respond. Correct responses appear in bold type below, Score 1 point for each correct response and 0 points fo each incorrect or no response. ‘Time Bonus: Ifall three item sets are completed in § minutes or less, add 1 point to the patient's score, ‘@ Start Time SetA SetA, SetB em [Renee [Sve em | _Repone [sere iter [tease [See mi «(fo mn moo ol 11° m2 5 [t[o a exalt ta 2 6 [fo mS 1 [e aS 7 /tI[0 5 7/1 Y{e mA 2 [7/9 At 6 [fo es, 2 [+ fe 5 67) AS. 2 [fo cs 1 [t Je 6 3 [tf A 7 hfe 5 3 [fe me é [ie Ag. 3 [apo 7 s [ife 78 2 fe A +p 3 6 |t{e ws Tle A 6 [tf 8 a [ajo no 3 [fo Aa 3 fifo 0 3 [a fe an ale Al s [1[o an. @[tfe ni 5 f° Aad 2 [io aia 3 [fo Sot A Subtotal Wax = Set A, Subtotal [ Wac=0) Set B Subtotal Wax = 2) Finish Time - Start Time = Total Time Minutes Raven's Coloured Progressive Matrices (RCPM) Score (A + A, +B + Time Bonus) 12 OA consteuctional, vi ‘Time Bonus: Completed in 5 minutes or less? Yes = patil, andl Callation (ax = 37)Supplemental Writing and Reading A. Writing Irregular Words to Dictation Writing Non-Words to Dictation Materials: Unlined paper, pen rections: Say, Write the following words. Dictate each word to the patient. Repeat each item once ifthe patient requests or does not respond. Discontinue Rule: Ifthe patient does not respond to five consecutiv items, discontinue the task and do not administer Writing Non-Words to Dictation. Write “DC” next tothe items you do not administer and score as 0 points. em i yacht guide ache debt | 5 knife | bargain laughter biscuit magician ‘courageous Writing frregular Words to Dictation Score ‘Materials: Unlined paper, pen Directions: Say, The next words are nonsense words, Write exactly what you heat. Dictate each word to the patient. Repetition: Repeat each item one time if the patient requests or does not respond, Discontinue Rule: Ifthe patient does not respond to five consecutive words, discontinue the task, Write “DC” next to the items you do not administer and score as 0p ie Sore 1 fess 2. unt deat dosh | shab aponster 7_poliket aldinger 9 limponit ‘lobter Uiriing Non Words to Ditation Score [] Supplemental Writing and Reading S13©. Reading Irregular Words Materials: Stimulus Book Directions: Turn to page 80 in the Stimulus Book, Say, Read these words aloud. Present the rest ofthe items. Discontinue Rule: Ifthe patient does not respond to five consecutive items, discontinue the task, Write “DC” next tothe items you do not administer and score as 0 points, acht guide: 7 1 ache 1 debt H _ knife 1 bargain 1 Taughter 1 biscuit 1 9, magician| 1 10. courageous 1 Reading Irregular Words Score [| @har=10) Reading Non-Words ‘Materials: Stimulus Book Directions: Turn to page 82 in the Stimulus Book. Say, The next words are nonsense words, Read them aloud, Scoring: Allow for reasonable variations in the pronunciation of non-words (eg, aldinger can be read with a soft ot hata g; globe with along or short o). Discontinue Rule: Ifthe patient does not respond to five consecutive items, discontinue the task, Write “DC” next to the items you do not administer and score as0 points. em Sore fess unt 5. deet 1 dosh 5 shab 7 poliket aldinger limponit globter T 1 1 1 1 aponster 1 1 1 1 1 Reading Non-Words Score = 14 \2/ supplemental Writing and ReadingPatient's Reading Score ‘A. Comprehension a of Sentences B, Reading Commands C. Written Word-Object Choice Matching D. Whitten Word-Picture Choice Matching E, Pleture-Written Word Choice Matching Spoken Word-Witten Word Choice Matching |__tana] 6. Letter Discrimination HH. Spelled Word Recognit L Spelting i Total va] Reading Score tn} usetacatetot.a) Reading Score tit] eetoeseite co) writing ‘A. Writing Upon Request 8, Writing Output L_ €. Wing ictaton co E.Aphabet and numbers [___ms & Oittedetersand rer on G. Copyinga Sentence Writing Total a 2S Whiting Score 4] (Use rocatetnet +10 Writing Score 14} usetocaette Cop 4 Score Summary Refer Worksheet Battery. Language Quotient (LQ) Spontaneous Speech Score 20) cordon Pr 1) Auditory Verbal Comprehension Score frtaandca (Record Form ar 1 | Repetition Score cit record Ferman) Naming and Word Finding Scare 100) Record Frm Part Reading Score ora Writing Score orta UL Language Quotient (La) Prorated Reading Total Directions: Ifthe patient’s Combined Score on Reading tasks A and Bis greater than or equal to 2) 50, and tasks C-Iare not administered, calculate the patient’s Reading Total using thi formula: 100 ~2(60 patient's Combined Score). Prorated Writing Total Directions: f the patient's Combined Score on Writing tasks A-Cis greater than or equal to (2) 40, and tasks D-G are not administered, calculate the patient's Writing Total by multiplying the Combined Score by 2 Score Summary Worktheet &/Apraxia "son Apraxia Total sate] +6 Cal Constructional, Visuospatial, 1nd Calculation Apraxia Score (Usetocateuateco) A. Drawing) 8. Bock Dean ms] C. Calculation sana D. Raven's Coloured ] Progressive Matrices sna Constructional, Visuospatial, and va Calculation Total Constructional, Visuospatial, and Calculation Score (Wsetocaletteca) Cortical Quotient (ca) / a i UICC UL Spontaneous Speech Score IRecoedForm Part), ‘Auditory Verbal Comprehension Scorefertgandca (RecordForm Pat Repetition Score (Beco Form Pat) Naming and Word Finding Score (RecordForm Par Reading Score rca Writing Score forca Apraxia Score Constructional, Visuospatial, and Calculation Score Cortical Quotient (CQ) 16 Supplemental Writing Pationt’s and Reading Score A Whiting regular Words toDictation eet 8, Writing Non-Words toDictation a C. Reading regular Words fin , Reading Non'Words — |_twa¥} \o/ score Summary Worksheet