PROFORMA FOR FLUENCY DISORDERS / KUNNAMPALLIL GEJO JOHN

PROFORMA FOR FLUENCY DISORDERS

Name:                                                                                         No:                                                  Date:

Age/Gender:                                                                    Student clinician:                                     Informant:

Mother tongue:

Presenting complaint:

Onset/Nature of the problem:

Family history:

Reaction to the problem:

Variation in stuttering:

                  Sound/ word/ language specificity:

                  Situation specificity:

                  Individual specificity:

                  Word position specificity:

Consistency in errors:

Anticipatory behaviour:

Avoidance behaviour:

Coping mechanism (if any):

OSME:

Language skills:

Secondary language skills:

Speech skills:

           Respiration:

           Phonation:

           Articulation:

           Prosody:

           Rate of speech:

           Intelligibility of speech:

Components of stuttering:

           Core behaviors:                                                                                                               Reading/conversation:

         Secondary behaviors:

         Feelings and attitudes:

         Naturalness of speech:

Tests administered:

         Results:

Severity of the problem:

Previous history of treatment:

Provisional Diagnosis:

Recommendations:

                                                                                                                                                                Signature of the Staff:

KUNNAMPALLIL GEJO JOHN