PROFORMA FOR CEREBRAL PALSY / KUNNAMPALLIL GEJO JOHN

PROFORMA FOR CEREBRAL PALSY

Name:                                                                   Age/Gender:                       H.No:

Date:                                                                     Informant:                            Mother tongue:

Student clinician:

Presenting complaint:

Onset of the problem:

Birth History:

Pre-natal:

Peri-natal:

Post-natal:

Family History:

Medical History:

Developmental History:

1. Motor milestones:

                Head control:

                Turning over:

                Crawling:

                                Sitting with support:

                                Sitting without support:

                                Standing with support:

                                Standing without support:

                                Walking with support:

Walking without support:

                Bowel & bladder control:

2. Sensory development:

                Hearing:

                Vision:

3. Language development:

                Vocalisations:

                Babbling:

                First word:

                Phrases & sentences:

Motor Behaviour:

                Muscle tone:

                Muscle control:

                Involuntary movement:

                Ambulatory skills:

                Co-ordination:

Speech Skills:

                Respiration:

                Phonation:

                Articulation:

Intelligibility:                                        Parents                     Clinician                   Others                                           

                                       

                                         Word level       

                                         Sentence level

DDK:

Resonation:

Prosody:

Rate of speech:

Vegetative Skills:

                Sucking:

                Swallowing:

                Chewing:

Biting:

                Blowing:

                Drooling:

Reflexes:

OSME:

Mode of communication:

Language Skills:

                Comprehension:

Expression:

Languages exposed to/ languages known:

Language Test Administered:

                Results:

Previous treatment taken:

Secondary Language Skills:

                Reading:

                Writing:

Scholastic Performance:

Cognitive Ability:

Associated problems if any:

Provisional Diagnosis:

Recommendations:                                                                                               Signature of staff:

KUNNAMPALLIL GEJO JOHN