PROFORMA FOR ARTICULATION/PHONOLOGICAL DISORDERS / KUNNAMPALLIL GEJO JOHN

PROFORMA FOR ARTICULATION/PHONOLOGICAL DISORDERS

Name:                                                                                        No:                                                  Date:

Age/Gender:                                                                    Student clinician:                                     Informant:

Mother tongue:

Chief complaint:

Onset/Nature of the problem:

Awareness:

Reaction to the problem:

                           Self:

                           

                           Parents:

                           Others:

Avoidance behavior:

Communication model at home:

Language specificity/ Dialect variation:

Family history:

Medical/surgical history:

Developmental history: (normal/delayed)

                               Motor development:

                               Sensory development:

                               Speech and language development:

Language skills:

Secondary skills:

OSME:

DDK:

Speech skills:

Articulatory skills:

               

                  Test administered:

                  Analysis:

                  Position specificity, if any:

                  Discrimination: (inter/intra personal)

                 Consistency of error:

                 Stimulability:                                                                                   Auditory/Visual/Kinesthetic

                 Key word:

                 Percentage of correct consonant (PCC):

Intelligibility rating:                                                                                             Good/ fair/ poor

Word level:

Parents:

Strangers:

Sentence level:

Parents:

Strangers:

Rate of speech:

Speech sample recorded: (file name)

Ability to imitate oral movements: yes/no

Mention the type of behavior (struggle/groping/trial & error)

Evident during the production of phonemes:

Previous intervention:

Provisional diagnosis:

Recommendations:

                                                                                                                                                                           Signature of staff:

 KUNNAMPALLIL GEJO JOHN