100%(3)100% found this document useful (3 votes) 10K views16 pagesWISC-IV Record Form
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content,
claim it here.
Available Formats
Download as PDF or read online on Scribd
uu =
oot acon. Record Form
WECHSLER INTELLIGENCE SCALE FOR CHILDREN"
FOURTH EDITION ~ SPANISH Subtest Scaled Score Profile
Child’s N: Verbal Perceptual Working } Processing
ae oe . Comprehension Reasoning. ‘Memory Speed
Examiner's Name. = St YC CO GAD Pon MR Pom] OS LN aM] cD ss CH
Calculation of Child’s Age s
Year ‘Month Day 7
Date of Testing a eects) perce uainer eri eal Veneaes
Date of eee eae eae ee ei are
ge at Testing Sasso rivet eilrojtetitetiret| sist tel ete sce
Total Raw Score to Scaled Score Conversion cies ec e ee
Subtest | Raw. Scaled Seores fa}> 2 + ele e © ole o ole oo
ae ee stsecs) sete dt|sctje ce
Siniates Ht [Zesuaoraeerios le peererenesey| omreneey [Ree co
Dig Span aioe elie: |verrrerrertat| srtstires|errretrs
ape ee ole ew ole we ele we
ble ee ele ow ole ew ele we
: Sle ee ole ew ole ow ole we
Teter Naber Seq, | Peedi ieee | eee eeics
ae a este eiie: fic totiettieil ettolrell errata
a cee ecc sce scce| ccs
Symbol Seah
(Picture Complation) Composite Score Profile
(Cancellation) vol [PRI Wat PSL FSIQ
Uafurnation)
‘Ateti) 160
Sums of Sealed Seores
Verbal Pere Work. Proc. Full 0
Gimp. Tove Mer Speed See 1
Sum of Scaled Scores to Composite Score Conversion 140
|_Us
Sun af si Adjusted
sate | Sealed | C™EP®SH® | Catone | FHPUBHON| Percentile | 120
Soares Interval Bank
i, | 1204
eral Comp. a 1
E = 110-|
7 = =| 1004
Pf |
Percentile Rank Adjustment |
Par Eastin TUS Edessa |
Tard | Chssifenin | OR | Exprence 70 |
eo |
PEARSON ©PsychCorp | z
——— z
copy © 2005s Pos 50
To reorder WISC-IV _seahisrseved. iene Une Stes of re,
Spanish Record Fors, 7090112 ABcDe 40
call 1-800-211-8378 orsssvsoasAnalysis Page
RENCRe eer
Beas 5 Tana ne phe. ee
Bios Ses pi esis (CUTS a cee
| VCI-PRI [ver ru i
[pee vor wast [ra va
| 2 [ver-Pst vet 2st
eee rrr = on
[iain PRI PSI mu 7a l
Will PSL on 7 t
Digit Span — Letter-Number Sea, | ns x
= © | Coding Symbol Search a a
‘Tinerites Picture Coneep’s [a a |
For critical values and overall base rales, refer Tables B.1-Bal For adjusted base rates, roles to Table C0 or Table C11,
engths and Weaknes:
Se Mean
eee
Weakmess Overall
(S)or(W) Base Rate
Sealed eal
Block Design
Similarities
Digit Span
Picture Coreen
Coding I
Vocabulary ie
Letter Number Se
Matrix Reasoning
Comprehension I
Symi Search I
For atengths and wealnesies rr to Table BS
‘Sum of Sealed Scores
‘Number of Subteste
“Mean Score
7 The overall mean Is caleuated ram the 10 core wbasts
Process Analysis a erste als Ce
‘etal Ray Score fo Seale Sore Conversion
one Pe
Longest Digit Span Forward (DSP)
Baek Design None Bons Lange Digit Span Bakard (DSB)
Dig Sp Foard Tor bas rate nfrmation, refer to Table BT
Pai tae 1 Discrepancy Comparison
eae eee ea ee
a = LDS? - LSB
For ase rae infarnation tor Wo DIO BS
For scaled scores refer to TableAS.
ea eae
Sci ees
Bloc Design ~ Black Desin No Time Bonus
Digit Span Forward — Digit Span Backward
Canelaton Random Sractared
Coding ~ Coding Cony1. Block Design @ tisiine sores Avo (CD tens 14
Set Revere Discontinve Score
Apnocrtent gD igsesesueeteaten © ie Teen S86 2p
i cer ofthis 0 ites ge, conseehe ters 8 Sar 0 pois
aes eee adios pecedig ita svesoi ems 3-1: Seo: he appcprate me Bont cre
reves ores um wo consestie EDN
eet ore ae cen. Hens 13: Saree 2 int
ems 14: Se 0040s
See rd
Reims co ood
Cee
Dery need
ae
1. Child | ‘Tad ‘Teal
onl Modet 30" yn/oo oc ma tat
Examiner | | o12
7 7 : / a ta Teal
‘Model 5" N + Zot
iH 45 YN aes
4s" | Ty
and Picture yn | Hare
+ 7
Picture 4" YN
Omeaa
Picture 4“ YN
= £ a
6
{ Picture 18 YN
i i fate ae | o 4
7 | |
Picture 18 YN
i - a co ae
a =
a Picture 18 YN 4
Gal i Onn
oC
E Picture 18 YN 8 a0 1
a LU [0 eae
10,
“= Picture | YN 30 50 140
i One ESRC
i | { |
zi Picture 10" | | yn] ‘eam sty a0 130
Oo | 0 4567
2
[a Picture 120" YN | nam sm 99 1
0 46567
3.
Picture 120° YN
| am sum 2.90 19
| : [0s saaesimola
ry | | |
Picture 0 | YN peepee re
0 4567
Total Raw Score
(Maximum = 68)
Block Design No Time Bonus (BDN)
Total Rawy Score
(Maximum = 50)2. Similarities AX wien
Sart Reverse Discontinae sore
‘Ages 6-8: Sun, thn em £ ‘Ages 9-16:Scre of Dor ton ether Aes Hem 1: Score Bt pint
‘Ages $11: Sample on tore 2 ofthe fist wo ers en, anise “ersecative ems 223: Score, 1,02 pais
‘Ages 1216S thea hen 2 preceding ts in eve ode rth score of See Simul: Hos or
ro cnsetie pet complersginses
are cbtaned
7.
o1
o12
3B
o12
+
012
o12
@
o12
2G =|
o12
&
012
x eae
o12
10.
o12
Lz é itd
o12
2B
012
1B
o12
ms =
o12
rs 2
o12
16. a a |
o12
rc a
o12
1%
012
“Ifthe child does not give a perfect response, provide the response indicated in the Stimulus Book,2. Similarities (Continued)
Discontinue after $ consecutive scores of 0
o12
i ue
ore
21. e :
o12
2.
012
= : oe
o1g
tao —
o12
+9) Incorrect pronunciation will change the stimulus meaning eee
(Maximum = 47)
. Digit Span Ani
set icone sre
ED cc ign sos Toa Soetoro ec
Forte ah en tea
‘Bachovard: Sample, then item 1 (Backward: Afr scones of 0 on, Total Raw Score ior DS Fenward and Backward, respectively
ah fae eee
BOO auE TE
Eee
Number of dg ralled on stl score | pintor
Ds rsd and Bait, epee
Becca ier cy
er SOS coca SSS
o1
on
or
[or
on
o4
=o o4
=6 ee om
=7-4 oa]
~8-3 jou
-2-3-8 o1
=1-6-8 on
9-7-6-3 o4
3-1-5-4 on
-1-2-4-6-9 [or
=9-1-7-8-3-5 [01
o12
Di ws | pig o
‘Maximum = 16) ‘(Maximum = 16)
Total Raw Score
(Maximum = 32),4, Picture Concepts [1h slits
a
MD see seint totes
es 9-11: Samples A&B the
Ages 12-16 Samples. 9&8 hen tern
Ite
Ages 9-16: Sco cn eter
feito ts he, acini
precting tems inrevese octet
‘wo comet pret scr
Disonige
Aber
Commertve
sors of
Score
See ort pint
(Cone napnses ein colo
i. 1 2 8/4 5 6|7 8 9 DK} o 1
uw 12 3/4 5 6/7 8 9 DK} o 1
Bw 12 3[4 5 6|7 8 9 DKJo 1
12 8/4 6 6[7 8 9 DK} o 1
wi 2 3/45 6/7 8 9 DK} 0 1
wo 1 2 3 4/5 6 7 8/9 10 1 wDKJO1
w 1 2 8 4/5 6 7 8]9 10 11 wpdK}o 2
1 2 8|4 5 6 DKJO 1 fo 1 23145 617 8 9 DK} 0 1
Di sls 5 6 vKlon ‘a. 1 2 8/4 5 6|7 8 9 DK} 0 1
& 12 8/4 5 6 DKJo1 2 12 3 4/5 6 7 8/9 10 1 12DKiO1
% 12 3/4 5 6 DKJOD 312 3 4/5 6 7 8/9 10 1 12DK}01
w. 1 2 3/4 5 6 DK|% 2 2 123 4/5 6 7 8|9 10 1 12DK]01
1 2 8/4 5 6 DK/O 1 % 128 415 67 8)9 10 1 woKlot
1 2 8/4 5 6 DK/O? 2% 12 3 4/5 67 8/9 0 1 woKloa
a 12 3|4 5 6|7 8 9 DK} 1
% 12 3 4/6 6 7 8|9 10 1 2DKlo 4
"TF the child selects pictures 2, 6, & 8, query Total Raw Score
1s indicated in the Stimulus Book (Maximum = 28)
5. Coding © (Time Lit: 12
St
‘Ags 6-7: Gdng Soles ten Ts es
‘Ages 8-16 Cg Sarple or then Ts ems
Mm em arts
Dit Sarg eythane
Score point er each comet response
of *
Coding A Time Bonus Scores for Perfect Performance
TaecuetMeine ao -
rent ao Seon leony | H6-120 111-115 106-110 101-105 6-100 96-95 <5
Score | 59 60 lB6. Vocabulary Avrirm
Sut Revere Dicennne Score
Ags 6-8: 2205 Ages 6-16 Soe of Dor fon ether fers lems 1-4: coe 001 pie
Age 11s tem 7 fhe it wo fer ery nies cones ems 5-36: Se, 1,02 pine
gs 12-1609 preted ters. rvese ore rl tro Ses 0 ‘See Simul Book Tar2&
corseetve pict cet caind sanple responses
Tan
#6. -
012
012
7 i
o12
o12
10, =
012
WL
012
2 7
o12
BS :
o12
Mu = a.
o12
| 15.
o12
16, Laguna
o12
[ou
o12
+ Ifthe child does not give a perfect response, provide the response indicated in the Stimulus Book.
* Responses requiing&speieqery ae identified inthe Stimlus Bok6. Vocabulary (Continued)
Discontinue afer § consecutive scr
Tien rs
18
oie
19. i ee
o12
0, i
ore
2 at ts
ore
2.
o12
8.
o12
ors a .
012
35. . z
» 012)
26.
o12
a
ore
28. a
o12
28. at i cee
o12
30. a a
o12
aL
o12
3. 5
» o12
o12
ai - —
012
ore
36. cores
ore
* Responses requiring a specific query are identified in the Stimulus Book. Total Raw Score
+)) Incorrect pronunciation will change the stimulus meaning. (Maximum = 68)7. Letter-Number Sequencing Axim
Score Ort poitioceach is
Score
of
Ich is unable respond concta ste:
Discotage
(Quaint eros fon all tree
©
Child counts to three.
‘Ags 816 Soap, er tem |
N
N
Child recites alphabet to the letter C.
Alphabet
3: 6-7-M-Q-Z
T-Q-6-M- 3-2
2, |H-s -B-4-P-8
3.
&
IK
16 7-9-K-S-T
2. 3-6-G-J-L-Q
7-8-9-K- 1-7-6
L-2-J-6-Q-3-6
2
5
1
2.
3
%
GIL Q- 2-56
:
2
e
i
:
;
:
:
7)
J-2-U-8-A-5-C-4[2-4- §- 8-A-C- J -UlA-C-J-U-2- 4-5
10.
eHL
B-L-1-Z-5-H-2-W]it-2-5-
Total Raw Score
= 30)
(Maximum8. Matrix Reasoning CO sites;
2 eer Dacre a
Ags Supe ent ¢ Ags 1s Scepter nto tert cenesve Sti ort pot
Age @tteSamplec bent? fensgien ares pce enn Peete Cones
es sieSarpesiG esiher tt | encore altnatoneroapeetoes sors san fhe ee
echt conecrie hes
en aaa Item sans sme
1203 4 6 DK aii 2 3 4 6 KIO TL % 12 3 4 5 DKIO 1
123 4 5 0K m1 2 3 4 5 K[O1|[m 12 3 4 6 vK[O 1
123 4 5K wm 12 3 4 5 DK{O1|| 1 2 3 4 6 vk[O 4
Li’ 3 4 5 oc ee iw 1 2 3 4 5 DKKIO TL m1 2 3 4 6 KI[OL
212 84 50/0 1|| i 1 2 3 4 5s dk]O1|[ 9.1 2 8 4 5 DK[O 1
Ca ee ee wmii2 3 4 5 blot gi 2 3 4 5 DEI oO 1
Epos es lor] {is 1 2s 4 5 ox lO 1] [m1 2 3 4 5 vKpOd
B12 3 4 6 Kiotl[i 1 2 5 s 5 pwK[O7|[ ss. 1 2 8 « 5 oK[O 1]
612 3 4 5 Ki[O1][ = 12 5 4 5 KiO1||% 1 2 3 4 5 KIO 1
Epis ts lo r|[ a 1 2 3 4s x foul[s 12 3 « 6 KpOd
& 123 4s K/O1|| m1 2 3 4 5 peo dT ;
9 12 3 4 5 K/@1|[m 12 9 4 5 DK[O dL (Gales
1 1 2 3 4 5 DKIOL m4 1 203 4 5 DK{[O DT
Papua 5 xf % 12 8 4 6 DK[O DT
9. Comprehension A Alltems
set Howie acon =
Ag 6teten gs 9- 16 Scare of Ooo cher he xt Set orzpns
Agetichon2 ed pre See Sens Bb 3
Age Heth 4 isn ene el occ seat =
Pet corsa cine,
a Dientes
012
2. Cinturones de seguridad a
=> . ors
*3,Humo *
o12
4. Verduras ees
o12
Cartera : —
onthe
"6, Luces —
012
Policias an ae
012
8,Pelea
012
‘Ifthe child doesnot give a 2-point response, provide the response indicated in the Stimulus Book
* If the child replies with only one general idea, ask fr @ second response as indicated in the Stimulus Book.9. Comprehension (Continued) Discontinue ater 4 consecutive sores of 0
Ten (em
*9, Biblioteca 012
10. Inspeceionar carne 012
11. Bjereicio Gar
12, Perdén 012
*18, Noticias 0 ta
¥14. Doctores o12
15. Promesa o12
16. Demoeracia
o12
"17. Derechos de autor
o12
#18 Monopolio :
jonopolio aay
19, Estampillas ous:
% i OO
‘20, Tecnologia 012
* Te the chilé replies with one general idea, ask fora seeond response as indicated etnea cea
in the Stimulus Book. (Maximum = 40)
10. Symbol Search Gre Limit: 120°) aA All tems
sat Dionne Swe
0-75 Sach Sapte, © et cds Ue sein ay eke hs poe
race es tne ee Seba Non credom er Core
Ages 8-16: Symbol Search B Sample Items, Aft Total Rawy Sere is <0, emer 0.
Pes ny ar Tens
Compton Yeuber ‘Number Toa Raw Sore
Time Correct Incorrect11. Picture Completion @ vinerin 2 AD) atten
srt
Ages 6-8: Sale then fem
[Aes So: Srple en ten
[Ags 12-16 Sample hen Rem 10
Rovene
J
ate obtaed.
ges 9-16 Sr on ert
‘heft vo msg, inser
pececig tens inrevene det
©
Speen en cas
Gore mi)
Soest
tet tes
Discontinve
ie 6 consecutive
Score
Score Oe tit
See Sims ook or
sane spss,
Tena
S. Lapiz ‘La punta
-t 1. Chamarra La manga; El braze iat
+2. Zorro Oreja; Odo oa
2. Mano aa ae i on
4. Gato Bigotee ‘Peloss Barba o1
HED Campane | bia ep itn Tio oeia | Compns: Rina ma =
‘que hace que suene o haze ruido ‘Mango; Manija; La parte de en medio i
6. Nifia. (Adorno, Listin, Mofo) en el cabello Botén; Bolita wer
7. Espejo ‘El roflejo de la mufoea; La munca en | Le mueco; La museca en la mano o1
(coogi) inne
Hombre acre ab La aes Eos oma aa
Caer dl
9. Puerta Bisagra; Gosne; Perno; Charnela La parte de metal; Tornillos; Clavos;
14 Sartore le 4
as eed
BED 0. Hejns es
Un rw ns 1
“Ti Eiealera [Ear Rida tinwate [ee Pare Peal a1
12, Mueble Mani: Agarraders; lade: Botin | Bacra o4
18. Chnturé | opi Age an Hei | Py Cd as a wl a
{anaes te,
14, Reloj ‘Un Len el 11; Al niimero 11 le falta 1; Los ritimerns estiin mal
De enn de Desde 04
vr de
15. Care ett oie con gorit | Coa la Dx pte
(cong palo ernaneea | ee on
tc
16 Dados Tero ur ag pin daa] Bats Hp ia Tr
tal seep neet Use a o1
nue nena a
17, Foca/Bombillo/ | Filamentos: Cables; Hilitos; Alambritas; | Circuito; Conexin; Lazo; Cuerda; La
Bombilla | ce aco ove sats | ema qu veel nha
hcp eens) | prep dep tei on
incom que rede ia
stent i
18. Futbol El dibujo de Ia pelota en In players de} La pelata (de fthol); Bi no tree
Cede lneqanee ama) | paula mana com on
tsiapure ah rr
Tarot dr) Lara Wa 7
bicicleta Las rayitas; Aguas Charco A
20, Arbol ‘Los anillos; (Aros, Ruedas, Céreulos) en | Lineas; Rayas; Disetio; Rayitas;
‘ronan inne ria | rece on
nr Goa
4 Tf the child does ant give #I-point response point to the location ofthe missing part and say “Mira, le fala la manga” for Iter Lor
"Mira 1a falta la oreja (el odo? for Item 211. Picture Completion (Continued)
Discontinue after 6 consecutive scores of 0
‘Toei; Perna Clevo
22, Puente ‘Baleares del gue; Olas La
(rule, corentl agua 0 se
‘rd moreno: Dean dl gs o1
_ semueve del frst
23, Silbato ‘Ranara Bl hi, egleoy La cna para | Bl espacio de arriba; La cose
alaive coord La rsa que ace que on
(cuene sie La bolita de adeno;
Leabecura
A. Banda de rock | Cocrdas dole guitare; uoréss | Las lines (een) la aitarra: Cables o1
25. Cerdo (Ventanas, Orifice, Agajeroe, Lemar
ess, Ciel) nar Las o1
oan por doe se respira
26. Tina/Bafiera [La colsder; Plugar or doadoiw | Hl drealown endo
essa) el agua lhe; Bap o4
27. Bicieleta Cadena ‘Alamos; Cable; La cosa gue hase
cue abt se mun; Lacon o4
oe negra que va alrededor
28, Termémetro | (eruro, Acie, Liguid) ent tuto, | Mercurio, aj; La cons de abo 0
céreuo bla, punto El mercuro que va | est pistda;Linale de oo, Ri
abo Ligudo en el fndo, Le esa gue
se alfinds
"29. Navanja ‘Vena: Linea divisor: Gai La marea_| Lies: Rebeoad: Bpacos
qe divide lo gas; Un eegmenta; Una | Nembrana La esa Manca; Herts o1
seein
30. Pez ‘Aglln;Branquios La aguers por | Liss; Abertura; Las cosas
dande entre el sire; Las cosas dens | ga eto o1
lak por donde respira
31, Bnrejado ‘Una sein, prt) del enriado | Una barra; Una ies de maders
ances Raya o1
‘32. Supermercado | Las tiguetas envltre,eabiras) de | Nombres: Marcas: Bama
Ins lata Los apees qu an aleador| Paps; Las lt extn mal 01
a deta tas
38. Perfil cia Tawa de ariba del gos Elo La oh:
estana
‘34. Sombrillal aril; Rayo; Cll; Cone que haco | Alambre; eo; Bara Parte de metal ah
Paraguas que et paraguas se mantenga aberto.
35. Esqui acudtico | ois del bar bite; Coens mt —_| Blau qe va hacia ais Bl gan
gua queso del bare El motor aa | ose est ovina on
«etd fanconand,prnid, ese) __
36, Casa 1a smb el bol Sombre o1
37. Familia El suetador de los ranes; La cosa | Bot; Clips La eile
para ebechar oe pantalones; Una A
Dare de os tants; La heii de
Tos anes
38. Zapato Cie: La pert de etal que va “yo; Hen: Aaja Anil oR
slrdador el esl
* Ifthe child says ‘Sensillay” Popes,” or “Pepitas” say: Dime otra parte que le fata. Total Raw Score
* Ifthe child does not spontaneously point when providing a response inthis cokumn, ask the child to clarify (Maximum = 38)
his or her verbal response by saying, “Seiiflame nde falta.” Irthe child responds tothe query by point-
ing correctly to the missing part, sore the item 1 point.12. Cancellation @ cinerinis15) A\ ites
start Discontave
ges 616¢Seroe, ke 45 second fr ach ten
Pree te fe 1
Ta
pag
ns
(ee
a
nd
Score
Use the Seaing Template n check he cis espos
Sibrac Name Ire or Number Comet the Tot
aw Sere, et,
‘CARand CAS: Til Ra Scare tes 1 ard, especie
of
ing
ie
Total Raw
Decree
ime Bons Po
ox
7m
prec
‘Time in Seconds [ 45 40-44 30-34 0-29
‘Bonus Points: o i 2 3 _4 Total Raw Score
(Maximum = 136)
13. Information aA Al tens
sot towne Dont =
eestor (| Sesser © raceme of cue berlpe
Age tien 6 erp cnet Sie Simul ook 3 ral spor
Aes elon pees
eee
tem Response Item ne
Pie 01] | 18.000 O71
"2. Novia oa] |19.F6 Oa
3 Comida 01] | 20.0xigen0 0
4. Orejas o1 *21, Poblacién 0
5. Edad o1 22, Jeroglificos o1
8 Patas on 28, Hojas oq
7 Monedae oa] [Pas Osar oa
#8, Jueves on a 01
79, Hervir ___ oa 01
10, Semana oL o1
| 11. Marzo on o1|
2, Docena on 1
13.Colén eee 0 1] | *0.Londres oa
#14, Bstaciones OL 81, Diamantes_ OL
*15, Bstémago o1 92. Fisién o1
16. Aiio bisiesto on $3. Trementina _ o1
jimate jor Total Raw Score al
ie dd at pv pi repns prove apne ned ne (Maximum = 33)
Simos Bonk
© Responses requiring a spcitic query are identified in the Stimulus Book.14, Arithmetic @ crrerin 0 OD ters Avrosos
sat fevene Daconinue Sear
Ages: ten 3 ‘Age 6-16 Sere cH ere te ot fed cote See O01 it
Ages09: te 9 notes gen, nse precedes in scoot
Age 10-or en 12 tee rer wo cont pert
‘ae aie
Hem co Tecgnte Response. Seore ren Teguonce Response Scone
1 Pajaritos 0-1] |13.Bicicletas | © 1] [25.Cambio on
+2, Pollitos: 0 1] | 14, Pelotas 0 1) | 26. Salones o1
8. Arboles 0-1| |15.Manzanas 01) [27.Dinero o1
‘4. Mariposes| 01] [16Vacas | | 0-1] [28.Paseo on
5. Nueces © 1] | 17. Modallas | I © 1) | 29. Bicicleta_ o1
6 Libros 1] [18.Globos | 0-1 | 20. Temperatura| o1
7. Sombreros | 0 1| [19 Pajaros | 0 1] | 81. Juego ol
8 Galletas 0-1] | 20. Puntos 0-1] | 82. Coches on
9. Pedaros 0-1 [21 Premios 0-1] [82. Vuelo on
10, Centavos fot] [22 Pramas [o1| [4 Relies 0
11 Lipices 0-1] [ 23. Bstudiantes [ot eae
12. Dulees 01] [24 Revistas [ou (Maximum = 34)
" Ihe child des nat pve a I-poat response, provide the response indicted in the Stimalus Book
15. Coding Copy @ metincian AX siren
Sixt Discontinue Scar
Ages 67: Do rot adie ‘er 120 send Compare the chil’ spose tte id sno in Response
Ag #16: angle ens the Test ems Soot 1. Supra Number ncoect fom Nuner Conpete the
tl ae score 2200 enter 200.
Number Namber Number
Complete Incorrect Correct
rT
eta *
wo | =
Time Completion Time
Limit ‘Time Bonus Polnts
‘Total RawChild's Nam _ Parent/Guardian’s Name:
Grade:
Sex: Place of Testing:
School: é — Examiner's Name;_____
Behavioral Observations
‘School experience (e.g, total years in school, years in U.S, schools, residency history)
Referral source/Reason for referral/Presenting complaint(s)
Language (e.g., first/native/other language lif other than Spanish], Spanish fluency, English fluency, age of language
acquisition [first or second], articulation)
Physical appearance
‘Visual/Auditory/Motor problems (e.g., problem area; how problems] corrected (glasses, hearing aids, adaptive equipment,
‘not corrected])
Attention and concentration (e.g., normal, hyperactive, remains in/out of seat)
Attitude toward testing (e.g., rapport, eager to speak, working habits, interest, motivation, reaction to success/failure)
AffectiMood
‘Unusual behaviors/Verbalizations (e.g., perseverations, stereotypic movements, hizarre and atypical verbalizations)
Other notes
pe
rwenictooe ase [femeRe| —_ cox EDeeal| ca
SS =...
coeur crass fe me Ee
ees eyecare aean yay
Sener e rales (ees Tari ae
=a
PEARSON @PsychCorp
cease wisc-
To reorder WISCIV ,
Se wv
Spas Red Fans Seana aca bs Tesrsuiew ee
call 1-800-211-8978 78910112 ascot TOTES glrso1saly7avos!