PROFORMA FOR DELAYED SPEECH AND LANGUAGE
Name:
No: Date:
Age/Gender: Student clinician: Informant:
Mother tongue:
Chief complaint:
Onset/Nature of the problem:
Birth History:
Pre-natal:
Peri-natal:
Post-natal:
Family History:
Consanguinity:
Sibling History:
Nuclear/Joint Family:
Any other:
Medical History:
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:
Speech & language skills:
a)
Oral Speech
Mechanism Examination:
b)
Vegetative
functions:
c)
Speech skills:
d)
Language skills:
Mode of communication:
Regression, if any:
Languages exposed to:
Comprehension:
Expression:
Language test Results:
Behavioral deviations, if any:
Education:
Regular/special:
Age
of entry:
Performance
at school:
Reading
skills:
Writing
skills:
Provisional Diagnosis:
Recommendation:
Signature of the Staff:
KUNNAMPALLIL GEJO JOHN
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