SM量表简单记录表儿童姓名： 性别： 被询问者： 检查日期： 出生日期： 实足年龄： 序号（领域）结果序号（领域）结果序号（领域）结果序号（领域）结果0101010134.(S)67.(SH)100.(SD)1.(C)35.(O)68.(SH)101.(C)2.(O)36.(SH)69.(S)102.(S)3.(C)37.(C)70.(SD)103.(O)4.(S)38.(SH)71.(SD)104.(S)5.(SH)39.(C)72.(C)105.(SD)6.(S)40.(SH)73.(O)106.(L)7.(O)41.(SH)74.(C)107.(C)8.(L)75.(SD)108.(O)9.(S)42.(SD)76.(L)109.(SD)10.(L)43.(S)77.(O)110.(L)11.(C)44.(SD)78.(S)111.(O)12.(SH)45.(L)79.(S)112.(S)13.(S)46.(SH)80.(L)113.(L)14.(SH)47.(SH)15.(C)48.(S)81.(SD)114.(SH)16.(O)49.(SH)82.(SH)115.(SD)17.(L)50.(SH)83.(SH)116.(O)18.(SH)51.(O)84.(C)117.(SH)19.(L)52.(SH)85.(SD)118.(SD)53.(SH)86.(SH)119.(O)20.(SH)54.(S)87.(SD)120.(SH)21.(SH)55.(L)88.(O)121.(O)22.(SD)56.(O)89.(S)122.(L)23.(S)57.(C)90.(L)123.(C)24.(S)58.(C)91.(C)124.(C)25.(C)59.(SH)92.(S)125.(S)26.(SD)60.(SH)93.(O)126.(L)27.(SD)61.(C)94.(C)127.(SD)28.(C)62.(O)95.(C)128.(C)29.(L)63.(S)96.(S)129.(S)30.(SH)130.(L)31.(SH)64.(SH)97.(SH)131.(L)32.(L)65.(O)98.(SD)132.(O)33.(O)66.(C)99.(SH)总计：SH_分，L_分，O_分，C _分，S_分，SD_分粗分：_分；标准分：_分；最终评定：_标准分及评定结果6分（重度）7分（中度）8分（轻度）9分（边缘）10分（正常）11分（高常）12分（优秀）