7/26/2019 FORMULIR PEMERIKSAAN INTELEGENSIA

1/4

FORMULIR PEMERIKSAAN INTELEGENSIA

Formulir Daftar Isian Wawancara Orantua

Nomor r!istrasi "###############

P!m!ri$sa "###############

Data Umum "##############%%

Nama "##############%%

Alamat "##############%%

Tanal la&ir'Umur "##############%%

(!nis K!lamin "##############%%

P!n)i)i$an "##############%%

7/26/2019 FORMULIR PEMERIKSAAN INTELEGENSIA

2/4

NO DAFTAR PERTANYAAN ANAK USIA 1 6 BULAN YA TidakKet Jika

Tidak

1Apakah mata anak dapat menik!ti "enda #an die$ak e$akkan

ke ki$i dan ke kanan%

& Apakah anak dapat menatap ata! mempe$hatikan 'e'!at! "enda#an mena$ik (a$nan#a )minima* &+ detik,%

-Apakah anak dapat menankat kepa*a dan dada pada p.'i'i

tenk!$ap denan men#ana kepa*a%

DAFTAR PERTANYAAN ANAK USIA 6 1& BULAN YA TidakKet Jika

Tidak

1Apakah anak dapat me$e'p.n "i*a mendapat *am"aian tanan da$i

.$an *ain%

&Apakah anak dapat men!*an kem"a*i kata kata #an

di"e$ikan%

- Apakah anak dapat men!n/!k an.ta "adann#a%

0

Apakah anak dapat men!nakan tanan ata! /a$i /a$in#a !nt!k

memindahkan "a$an da$i 'at! 'i'i ke 'i'i *ain denan !k!$an#an "e$"eda "eda da$i ke2i* ke "e'a$ ata! 'e"a*ikn#a 'e'!ai

in't$!k'i%

*I+ARA ATAU *A,ASA

NO A)a$a& $!lu&an cara -icara )an .!nuca.an $ata .a)a ana$/ 0a Ti)a$K!t 1i$a

Ti)a$

1 3en.2eh a455i44!44

& 3en.2eh & kata ma4pa4da4

- Bi2a$a !/!n!/!n kata

0 3e$ankai 'at! kata

7 3e$ankai & kata

6 3e$ankai - kata

8 St$!kt!$ ka*imat #an "e*!m "et!*

9 Pen!2apan kata "e*!m /e*a'

No A.a$a& ana$ m!n!rti saat )ia1a$ -icara/ 0a Ti)a$ K!t (i$a0a

1 K.ntak mata "e*!m ada

& Dipani* "e*!m "e$e'p.n'

- Be*!m mene$ti pe$intah pendek

0 Be*!m mene$ti pe$intah pan/an

7 3en/a(a" tidak 'e'!ai denan #an ditan#akan

MOTORIK ATAU GERAK

NOA)a$a& $!lu&an .a)a cara ana$ m!nuna$an tanan )an

1arin2a/0a Ti)a$

K!t 1i$a

Ti)a$

1 Anak "e*!m "i'a apaapa

& Be$e$ak kanan *e"ih akti: da$i ki$i

- Ki$i *e"ih 'e$in di!nakan di"andin kanan

0 Anak "e*!m memean "enda

7 Tanan 'e$in menepa*

7/26/2019 FORMULIR PEMERIKSAAN INTELEGENSIA

3/4

6 Ada e$akan a"n.$ma* ata! /ana*

NoA)a$a& $!lu&an .a)a cara ana$ m!nuna$an tun$ai )an

$a$in2a/0a Ti)a$

K!t (i$a

0a

1 Be*!m dapat d!d!k 'endi$i

& Be*!m dapat "e$/a*an

- Saat di"e$di$ikan ked!a kaki men#i*an) Tanda !ntin,

0 Saat di"e$di$ikan ked!a kaki diankat tidak ma! menapak

7 Saat di"e$di$ikan /in/it

6 Saat "e$/a*an /in/it

TINGKA, LAKU DAN INTERAKSI

No A)a$a& $!lu&an .a)a tin$a& la$u ana$/ 0a Ti)a$ K!t (i$a 0a

1 Tidak "i'a d!d!k diam

& Ban#ak "e$e$ak

- S!ka men#endi$i

0 ;!ek

7 Pe$hatian m!dah "e$a*ih

6 S!ka men#akiti di$i 'endi$i

NoA)a$a& $!lu&an .a)a cara ana$ -!rmain' -!rint!ra$si )

ana$ lain )an mainan/0a Ti)a$ K!t (i$a 0a

1 S!ka men#endi$i

&

7/26/2019 FORMULIR PEMERIKSAAN INTELEGENSIA

4/4

M!nulis

1+ Be*!m dapat men!*i' h!$!: a"/ad

11 Ada h!$!: #an te$"a*ik

1& Ada h!$!: #an te$tina* da*am men!*i' kata

1- T!*i'an tidak $api

10 3en!*!' *am"at

17 T!*i'an "e'a$"e'a$

M!m-aca

16 Be*!m dapat mem"a2a h!$!: a"/ad

18 Be*!m dapat mem"a2a tanpa mene/a

19 3em"a2a te$'endat'endat

1= 3em"a2a "e*!m *an2a$

&+ Tidak mene$ti apa #an di"a2a

Be$hit!n

&1 Be*!m mene$ti a$ti anka

&& Ada t!*i'an anka #an te$"a*ik

&- Ke'!*itan da*am men/!m*ah

&0 Ke'!*itan da*am menhit!n pen!$anan

&7 Ke'!*itan da*am menhit!n pe$ka*ian

&6 Ke'!*itan da*am men#e*e'aikan h!t!nan #an "e$h!"!nan

denan "aha'a

A)a$a& .!n2a$it atau $!lainan lain 2an m!n$&awatir$an

.a)a ana$%0a Ti)a$ K!t (i$a 0a

1 Ke*ainan "ent!k mata

& Ke*ainan "ent!k te*ina

- Ke*ainan "ent!k m!*!t dan $.na m!*!t

0 Ke*ainan "ent!k t!"!h dan an.ta e$ak

7 Ke*ainan "ent!k kepa*a

6 Ke*ainan :!n'i pendena$an

8 Ke*ainan :!n'i pen*ihatan

9 Ke*ainan p$.'e' makan dan mene*an

= Ke*ainan "atan t!"!h ) *ehe$ *ema' p!n!n *ema' p!n!n

me*entin,

,ASIL WAWAN+ARA"

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%