PROFORMA FOR CLEFT PALATE
Name: No:
Date:
Age/Gender:
Student clinician:
Informant:
Mother tongue:
Chief complaint:
Onset/Nature of the problem:
Cleft type:
Birth History:
Pre-natal:
Peri-natal:
Post-natal:
Family History:
Feeding habits:
Vegetative skills:
Medical history:
Surgical history:
(a)
Repair of lip:
(b)
Repair of palate:
Other management:
(a)
Prosthodontic:
(b)
Orthodontic:
Developmental history:
1. Motor milestones:
a) Head control:
b) Turning over:
c) Crawling:
d) Sitting with support:
e) Sitting without support:
f) Standing with support:
g) Standing without support:
h)
Walking with support:
i) Walking without support:
j)
Bowel & bladder control:
2. Social development:
a) Social smile:
b) Recognition of mother:
c) Discrimination of strangers:
d) Solo play:
e) Group play:
3. Sensory development: Hearing/ Sensory
4. Language development:
a) Babbling:
b) First word:
c) Phrases & sentences:
Scholastic performance:
OSME:
Speech skills:
Respiration:
Phonation:
Articulation:
Resonation:
normal/
mild/ moderate/ severe
Test
administered:
Findings:
DDK:
Intelligibility
rating: 3
point scale/ 5 point scale
(a)
Word level:
(b)
Sentence level:
Stimulability:
Auditory/Visual/Kinesthetic
Rate
of speech:
Prosody:
Language skills:
Speech
and language stimulation at home:
Language
exposed to:
Comprehension:
Expression:
Language test Results:
Secondary language skills:
Reading:
Writing:
Provisional diagnosis:
Recommendation:
Signature of staff:
KUNNAMPALLIL GEJO JOHN
No comments:
Post a Comment