VISUAL FORM DISCRIMINATION RECORD FORM

Nome: ________________________________________________________ Data: ___ / ___ / ___

Idade: __________ Sexo: ________ Escolaridade: _____________ Examinador: _______________

Demonstração Item A ______ ( 3 ) B _______ ( 3 )

Erro Maior Maior Não

Item Correto
Periférico Rotação Distorção Respondeu
1 ________ ( 3 ) ________ ( 4 ) ________ ( 2 ) ________ ( 1 ) ________
2 ________ ( 1 ) ________ ( 2 ) ________ ( 4 ) ________ ( 3 ) ________
3 ________ ( 1 ) ________ ( 4 ) ________ ( 2 ) ________ ( 3 ) ________
4 ________ ( 2 ) ________ ( 4 ) ________ ( 3 ) ________ ( 1 ) ________
5 ________ ( 3 ) ________ ( 4 ) ________ ( 1 ) ________ ( 2 ) ________
6 ________ ( 1 ) ________ ( 4 ) ________ ( 3 ) ________ ( 2 ) ________
7 ________ ( 4 ) ________ ( 2 ) ________ ( 1 ) ________ ( 3 ) ________
8 ________ ( 2 ) ________ ( 3 ) ________ ( 4 ) ________ ( 1 ) ________
9 ________ ( 2 ) ________ ( 3 ) ________ ( 1 ) ________ ( 4 ) ________
10 ________ ( 4 ) ________ ( 1 ) ________ ( 3 ) ________ ( 2 ) ________
11 ________ ( 3 ) ________ ( 1 ) ________ ( 4 ) ________ ( 2 ) ________
12 ________ ( 1 ) ________ ( 2 ) ________ ( 3 ) ________ ( 4 ) ________
13 ________ ( 3 ) ________ ( 1 ) ________ ( 2 ) ________ ( 4 ) ________
14 ________ ( 4 ) ________ ( 3 ) ________ ( 1 ) ________ ( 2 ) ________
15 ________ ( 2 ) ________ ( 4 ) ________ ( 1 ) ________ ( 3 ) ________
16 ________ ( 4 ) ________ ( 1 ) ________ ( 2 ) ________ ( 3 ) ________
Total ________ ________ ________ ________ ________

Observação: ______________________________________________________________________

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