Response Sheet

of
TM Regd. No. 564838
Copyright Regd. No A-732662005 DI 13 5 05

Dwarka Pershad (Chandigarh) PGIBBD-PV

S. K. Verma (Chandigarh) (English Version)
Please fill up the following Informations : Date
Name
Age Sex Education.

Sr. No. Test Variables Dysfunction Rating Score

Sub-tests 3 2
1. Remote Memory 0-2 3-4 5+
2. Recent Memory 0-2 3-4 5+
3. Mental Balance 0-2 3-4 5+
A. Attention and Concentration 0-2 3-4 5+
5. Delayed Recall 0-2 3-4 5+
6. Immediate Recall 0-2 3-4 5+
7. Retention for Similar Pairs 0-2 3-4 5+
8. Retention for Dissimilar Pairs 0-2 3-4 5+
9. Visual Retention 0-2 3-4 5+
10.
11.
Recognition
*PIK x100
a00-2
251+
3-4
200-250
5+
upto 199
12. Performance Quotient 60 61-80 81+
13. T.Q. On information 60 61-80 81+
14. T.Q. on Digit Span 60 61-80 81+
15. T.Q. on Arithmetic 60 61-80 81+
16. T.Q. on Comprehension 60 61-80 81+
17. Difference in P. CQ. and V. Q. 24+ 15-23 upto 14
18. Nahor and Benson Test 6+ 4-5 0-3
19. Bender-Gestalt Test 9+ 5-8 0-4
Total
Remarks Dysfunction Rating Score =

Estd. 1971 www.npcindia.com :(0562) 2601080

NATIONAL PSYCHOLOGICAL CORPORATION
UG-1, Nirmal Heights, Near Mental Hospital, Agra-202007
 2| Response Sheet for PGIBBD-PV
Sub-Test1. Memory Scale
I. Remote Memory

1. How old are you ?

2. Where were you born ?

3. (a) When were you married ?

(b) When did you start earning ?

(c) When did you left study/pass high school ?
4. How old is your youngest child/brother/sister?
5. When did you come first time in this clinic/department (Hospital) ?
6. When did you come here last time ?
II. Recent Memory

1. What did you eat in your last dinner ?

2. What did you eat this morning ?

3. What is the name of this month ?

4. What day is today ?

5. Who came to visit you or to whom youvisited yesterday?
II. Mental Balance

1. Recite Ato Z (Alphabet of any language).

2. Count backward from 20 to 1.

3. Count backward by minusing 3s starting from 40.

 Response Sheet for PGIBBD-PV3
IV. Attention and Concentration
1. lam going to say some numbers. Listen them carefully, when Iread them,
you will repeat them in the same order.
5-73 4-1--7G
538-7 61-5-8
1--6-4 9-5 29-763
3-41-79 6 6-158-3-9
7-2 5 94-83osl 4-7-1-5 3 86 O
4-72- 9-1-68-5 9 2883-17-4
2. lam going to read some more numbers but you will be required to repeat
them backward, for example, Isay 2, 5 you will say 5, 2.
85 28bolt law iseifa
4 3-7 85-1
8563 3 - 75-9
4-72- 9-1 oWi9.20 9-2 5 84iopnn
25 9 4 8-3
35-8- 61 9 2 6-37-14 8 5
85236194 2-8 459-71-3
V. Delayed Recall
Recallokobb
Iam going to read name ofsome objects. Listen carefully and when Iask you
to repeat, you will do so (read at the rate of one word per second and ask the
subject to repeat it after an interval of one minute).
1 2

Umbrella Fish
Flower Lamp
Clock Rupee
Picture Taj
Pencil Toy
4 | Response Sheet for PGIBBD-PV
VI. Immediate Recall

Iam going to read a few small sentences one by one. Listen them carefulv

because when Iam through Iwould like you to tell me the whole sentence as
precisely as you can.
1.
Ram got up from the chair, opened the door and went to market.
2. Patient was asked to lie down on the table, he was seen, medicine was

prescribed and was told to come next day.

3. Mohan did not have water in his house, he picked-up the bucket, went to
street well, filled it up and returned back.
VII. Verbal Retention for Similar Pairs

Now, Iam going to read to you a list of pairs, i.e., two words at a time. Listen
carefully. When Iname one word of the pair you will tell the second word of the pair
(read the pairs at the rate of 2 seconds per pair, with a pause of 5 seconds between
pairs; give an interval of 10 seconds after reading last pair and then present a
stimulus word of the pair and ask the subject to recall the 2nd word of the pair).
1. Tree Flower
2. Sweet Sour
3. Man
Woman
4. Day Night
5. Black
White
 Response Sheet for PGIBBD-PV5

Vll. Verbal Retention for Dissimilar Pairs

Instruction and administration procedure is the same as above for subtest VII,

with a difference that stimulus words are to be presented in the order as mentioned

for each of the trial. Ifsubject fails to give correct answer, correct it and proceed to
next stimulus Word. If all his answers are correct in first trial even then other two

trials are to be completed but in no case, pairs be repeated, only incorrect answers

are to be corrected.

Table-Black 4 2 1

2 1 5
Tree-High
Lamp-Uneven 1 5 3

Child-Bitter 3 4 2

Dream--Deep 5 3 4

IX. Visual Retention

lam going to show you a card, see it carefully. After some time (15 seconds) I

will take it away and when Iask you (after 30 seconds) to draw them, draw the
things you saw in the card from your memory on this paper (give a paper, a pencil
and an erasure to the subjectbut do not instruct whether he can use the erasure or
not).
6| Response Sheet for PGIBBD-PV
X. Recognition

lam showing you a card containing pictures of many objects, see the whole
card attentively (expose for 30 seconds). After some time (120 seconds interval) I
will place before you another card. From this you will be required to identify and
name the objects yousaw in earlier card (Do not tellthesubject, the exact number
of objects seen in first card and how many things he is yet to identify).

novenn

Summary of Memory Scale

Sub-Tests IV V VI VII VIlI IX X Total

Raw Scores

Converted
Scores
 Response Sheet for PGIBBD-PV7
Sub-Test II, Battery of Performance Tests of Intelligence
KOHS BLOCK PASS-A-LONG
Item No. Time Taken Remarks
Score Item No. Time taken Score

B,

B, B,

B B,

B B
Bs BA
B B
B7 Be

B, B,
B B

B0
Total Score Total Score
T. Q. T.Q.
Performance Quotient =

38038ATOT
 8 Response Sheet for PGIBBD-PV
Sub-Test lIl. Verbal Adult Inteligence Scale (VAIS)
1. INFORMATIONS 2. DIGIT SPAN
Discontinue after 7 consective Discontinue after failures on
failures response Both TRIALS of any item.
1. Ball DIGITS FORWARD SCORE =
2. Year DIGITS BACKWARD SCORE =
3. Thermometer TOTAL SCORE
n
4. Sun
5. Prime Minister
6. Guru Nanak
7. Flag
8. Lohri
9. Ramayana
10. Kuran/Bible
11. Women Ht
12. Independence 3. ARITHMETIC
13. Birbal Discontinue after 5 consecutive
14. Gandhi failures
15. Rubber Probiem Score
16. Taj Mahal 1or 0
17. Population 1.
18. Triveni 2.
19. Bombay 3.
20. Direction-Delhi-Madras 4.
21. Curd 5.
22. Dark coloured clothes 6.
23. Year-Weeks 7.
24.Temperature 8.
25. Ceylone 9.
26. England 10.
27. Geeta 11.
28. Meghdoot 12.
29. Mahabharata 13.
30. Vedas 14.
31. Delhi-Bombay Distance 15.
32. Lok Sabha
33. Veins TOTAL SCORE =
TOTAL SCORE
 Response Sheet for PGIBBD-PV |9
4. COMPREHENSION
Discontinue after 6 failures Score
Response
1. Engine
2. Clothes
*3. Health
4. Bad habbits
5. Movie (Cinema Hall)
6. City land
"7. Eatables
8. Credit
9. Envelope
*10. Cheque
11. Tax
12. Unity
13. EmptyVessel
14. Forest
*15. Child law
16. Driving Licence
17. Deaf man
18. Strike-iron
Total Score (Max. 36)
"If the subject replies with only one idea, ask for a second response.
Hephrase the test item appropriately saying. Tll me another reason why
(another thing people can do.)

SUMMARY OF VAIS
Sub-tests Information Digit Span Arithmetic Comprehension
Raw Scores
Test Quotlents =T.Q.
T.Q.
Verbal 1.a. N
10 Response Sheet for PGIBBD-PV
RESPONSE FOR NAHOR BENSON TEST
 Rosponso Shoot for PGIBBD-Py |11
RESPONSE FOR BENDERGESTALT TEST
12 | Response Sheet for PGIBBD-PV

SUB-TEST IV. NAHOR BENSON TEST

VII VII
Total
Total No. II III IV VI
Score

Figure wrongly
reproduced

SUB-TEST V. BENDER GESTALT TEST

Score
Perseveration 4
Rotation or Reversal 4
Concretism 4
Added angles 3
Separation of lines 3
Overlap 3
Distortion 3
Embolishments 2
Partial Rotation 2
Omission 1
Abbreviation 1
Separation 1
Absense of erasure 1
Closure 1
Point of contact
TOTAL SCORE

oA rts merved, PReoroductonin any fom ia aviolation of Copyright Act. Responso Sthet of PGI Batary of Brain Dystunction (PGiBaD-PV) (Eng) AP15