Date of testing:
..........................................................................................................................................
Name
.........................................................................................................................................................
Sex:
Male/Female Age: (Year and
month)......................... Date of
birth...............:...........................
Father’s
Name:...........................................................................................................................................
Mother’s
Name:........................................................................................................................................
Address.............................................................................................Grade/Highest
Education.................
Referred
by:..............................................................................................................................................
Examiner
.....................................................................................................................
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
শব্দভান্ডার (Vocabulary)
LDA
Start Point
Ages
6-8: Item 5
Ages
9-89 Item 9
|
M
Reverse Rule
All
Ages: Administer Items 1-4 in
forward
sequence if score of 0 or 1 on Item 5
or 6.
Ages
9-89: Administer Items 5 -8 in reverse sequence if score of 0 or 1 on Item 9
or 10
|
N
Discontinue Rule
After
5 consecutive scores of 0
|
Stop point
Ages
6-8: After Item 30
Ages
9-11: After Item 34
Ages
12-16:After
item 38
Ages
17-89: No
stop point
|
M
Scoring Rule
Items
1-4: 0 or
1
Items
5-42: 0,
1, or 2
|
শব্দ ভান্ডার
(Vocabulary)
Item
|
Response
|
Score
|
১. মাছ
|
|
0 or 1
|
২. কোদাল
|
|
0 or 1
|
৩. মানচিত্র
|
|
0 or 1
|
৪. ঝিনুক
|
|
0 or 1
|
৫. শার্ট
|
|
0,1or2
|
৬. জুতা
|
|
0,1or2
|
৭. টর্চলাইট
|
|
0,1or2
|
৮. গাড়ী
|
|
0,1or2
|
৯. নাসতা
|
|
0,1or2
|
১০. পাখি
|
|
0,1or2
|
১১. ক্যালেন্ডার
|
|
0,1or2
|
১২. গৃহপালিত
|
|
0,1or2
|
১৩. বেলুন
|
|
0,1or2
|
১৪. পুলিশ
|
|
0,1or2
|
১৫. কুমির
|
|
0,1or2
|
১৬. ঘন্টি
|
|
0,1or2
|
১৭. ঠেলাগাড়ী
|
|
0,1or2
|
১৮. সংখ্যা
|
|
0,1or2
|
১৯. ছুটি
|
|
0,1or2
|
২০. নৃত্য
|
|
0,1or2
|
২১. দোষারোপ
|
|
0,1or2
|
২২. আপ্যায়ন
|
|
0,1or2
|
২৩. খ্যাতিমান
|
|
0,1or2
|
২৪. তাড়াহুড়ো
|
|
0,1or2
|
২৫. উদ্দেশ্য
|
|
0,1or2
|
২৬. রুপানতর
|
|
0,1or2
|
২৭. দুঃসাহসী
|
|
0,1or2
|
২৮. AvMÖnvwš^Z
|
|
0,1or2
|
২৯. অপ্রাসঙ্গিক
|
|
0,1or2
|
৩০. উন্মোচন
|
|
0,1or2
|
৩১. প্রথা
|
|
0,1or2
|
৩২. দশক
|
|
0,1or2
|
৩৩. সমৃদ্ধকরণ
|
|
0,1or2
|
৩৪. একনিষ্ঠ
|
|
0,1or2
|
৩৫. তাড়না
|
|
0,1or2
|
৩৬. উদ্বেলিত
|
|
0,1or2
|
৩৭. প্রবনতা
|
|
0,1or2
|
৩৮. রোমন্থন
|
|
0,1or2
|
৩৯. উদ্ধত
|
|
0,1or2
|
৪০. সবিরাম
|
|
0,1or2
|
৪১. কুলঙ্গী
|
|
0,1or2
|
৪২. ধননতরী
|
|
0,1or2
|
|
Total raw score
|
|
ব্লক ডিজাইন (Block
design)
Start Point
Ages
6-8: Design 1
Ages
9-89: Design 3
|
M
Reverse Rule
Ages
9-89: Administer Items 1-2 in reverse
sequence
if score of 0 or 1 on Item 3 or
4.
|
N
Discontinue Rule
After
3 consecutive scores of 0
|
M
Scoring Rule
Items 1-4:
2 for a correct design on Trial 1
1 for a correct design on
Trial 2
0 for incorrect designs on
Trials 1 & 2
Items
5-13: 0-7
|
Design
|
Time
limit
|
Incorrect design
|
Completion time in seconds
|
Correct Design
|
Score (Circle the appropriate
score for each design.)
|
1.
|
30"
|
Trial 1 Trial 2
|
|
Y N
|
0 1 2
|
2.
|
60"
|
Trial 1 Trial 2
|
|
Y N
|
0 1 2
|
3.
|
60"
|
Trial 1 Trial 2
|
|
Y N
|
0 1 2
|
4.
|
60"
|
Trial 1 Trial 2
|
|
Y N
|
0 1 2
|
5.
|
60"
|
|
|
Y N
|
21"- 60" 16"- 20" 11”- 15" 1"- 10"
0 4 5 6
7
|
6.
|
60"
|
|
|
Y N
|
21"- 60" 16"- 20" 11" - 15" 1" - 10"
0 4 5 6 7
|
7.
|
60"
|
|
|
Y N
|
21"- 60" 16"- 20" 11" - 15" 1" - 10"
0 4 5 6 7
|
8.
|
60"
|
|
|
Y N
|
21"- 60" 16"- 20" 11" - 15" 1" - 10"
0 4 5 6 7
|
9.
|
60"
|
|
|
Y N
|
21"- 60" 16"- 20" 11" - 15" 1" - 10"
0 4 5 6 7
|
10.
|
120"
|
|
|
Y N
|
66"-
120" 46"- 65" 31" - 45" 1" - 30" "
0 4 5 6 7
|
11.
|
120"
|
|
|
Y N
|
76"-
120" 56"-
75" 41" - 55" 1" - 40"
0 4 5 6 7
|
12.
|
120"
|
|
|
Y N
|
76"-
120" 56"-
75" 41" - 55" 1" - 40"
0 4 5 6 7
|
13.
|
120"
|
|
|
Y N
|
76"-
120" 56"-
75" 41" - 55" 1" - 40"
0 4 5 6 7
|
|
|
|
Total raw
|
Score
|
|
mv`„k¨ (Similarities)
Start Point
Ages
6-8: Item 1
Ages
9-11: Item 5
Ages
12-89: Item 7
|
M
Reverse Rule
Ages
9-89: Administer Items 1-4 in
forward sequence if score of 0 or 1 on Item 5 or 6.
Ages
2-89: Administer Items 5 & 6 in reverse sequence if score of 0 or 1 on Item 7 or 8
|
N
Discontinue Rule
After
4 consecutive scores of 0
|
Stop point
Ages
6-8: After Item 20
Ages
9-11: After Item 24
Ages
12-89: No stop point
|
M
Scoring Rule
Items
1-4: 0 or 1
Item
5-26: 0, 1, or 2
|
মিল কোথায়? (Similarities)
Item
|
Reponse
|
Score
|
১. বাস (চার চাকা)
|
|
0 or 1
|
২. ফল (কলা)
|
|
0 or 1
|
৩. জুতা (পোষাকের অংশ)
|
|
0 or 1
|
৪. চামচ (খাবার খেতে লাগে)
|
|
0 or 1
|
৫. আঙ্গুর - লিচু
|
|
0,1or 2
|
৬. কলম - পেন্সিল
|
|
0,1or 2
|
৭. শার্ট - সোয়েটার
|
|
0,1or 2
|
৮. গরু - ভালুক
|
|
0,1or 2
|
৯. লাল - নীল
|
|
0,1or 2
|
১০. টেলিভিশন - খবরের কাগজ
|
|
0,1or 2
|
১১. এরোপেস্নন- বাস
|
|
0,1or 2
|
১২. গামলা-থালা
|
|
0,1or 2
|
১৩. বৃত্ত - চতুর্ভূজ
|
|
0,1or 2
|
১৪. কাঁধ - গোড়ালী
|
|
0,1or 2
|
১৫. শিশু - যুবক
|
|
0,1or 2
|
১৬. চিত্র - গান
|
|
0,1or 2
|
১৭. বাষ্প - মেঘ
|
|
0,1or 2
|
১৮. অধিক - অল্প
|
|
0,1or 2
|
১৯. ধনতন্ত্র - সমাজতন্ত্র
|
|
0,1or 2
|
২০. ভালবাসা - ঘৃণা
|
|
0,1or 2
|
২১. বসা - দৌড়ানো
|
|
0,1or 2
|
২২. প্রথা-ু অভ্যাস
|
|
0,1or 2
|
২৩. ¯^vaxbZv- আইন
|
|
0,1or 2
|
২৪. পাখী - ফুল
|
|
0,1or 2
|
২৫. শানিত - যুদ্ধ
|
|
0,1or 2
|
২৬. মসৃন - রুক্ষ্ম
|
|
0,1or 2
|
|
Total raw score
|
|
4. Matrix Reasoning
Start Point
Administer Sample Items
A and B first
Ages 6-8: Item 1
Ages 9-11: Item 5
Ages 12-44: Item 7
Ages 45-79: Item 5
Ages 80-89: Item1
|
M
Reverse Rule
Ages
9-11 and Ages 45-79: Administer Items 1-4 in reverse sequence if score
of 0 on Item 5 or 6.
Ages
12-44: Administer Items 1-6 in reverse sequence if score of 0 on Item 7 or 8.
|
N
Discontinue Rule
After
4 consecutive scores of 0 or after 4 scores of 0 on 5 consecutive items
|
Stop point
Ages
6-8: After Item 28
Ages
9-11: After Item 32
Ages
12-44: No stop point Ages 45-79: After Item 32
Ages
80-89: After Item 28
|
M
Scoring Rule
Items
1-35: 0 or 1
|
Item
|
Response
Options
(Circle
One)
|
Score
(0
or1)
|
|
Item
|
Response
Options
(Circle
One)
|
Score
(0
or1)
|
||||||||||
A.
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
|
18
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
B.
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
|
19
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
1
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
|
20
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
2
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
|
21
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
3
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
|
22
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
4
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
|
23
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
5
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
|
24
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
6
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
|
25
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
7
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
|
26
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
8
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
|
27
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
9
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
|
28
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
10
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
|
29
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
11
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
|
30
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
12
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
|
31
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
13
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
|
32
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
14
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
|
33
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
15
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
|
34
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
16
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
|
35
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
17
|
1
|
2
|
3
|
4
|
5
|
DK
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Total
|
raw
|
score
|
|
Maximum Raw Score: Ages 6-8: 28,
Ages 9-11:32, Ages 12-44: 35, Ages 45-79: 32, Ages 80-89: 28
Behavioral
Observations
|
Reason for
Referral/Referral Source:
|
Attitude Toward Testing
(e.g., rapport, work habits, interest, motivation, reaction to success/failure):
|
Physical Appearance:
|
Attention:
|
Visual/Auditory/Motor
Problems:
|
Language (dominant
language, language spoken in the home, expressive/receptive):
|
Affect/Mood:
|
Unusual
Behaviors/Verbalizations:
|
Other Remarks:
|
|
|
[1]
Last adaptation in 7th November 2008 .
Caution: Adaptation was done for the use of clinical purpose only. Strict
statistical procedure was not used. It was advised to avoid using this version
in research.
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