SLP - ORAL-PERIPHERAL EXAMINATION
SLP - ORAL-PERIPHERAL EXAMINATION | |
| |
|STUDENT’S NAME: | |DATE | |
| |
|SCHOOL: | |DOB: | |
| |
|Write WNL or YES or a checkmark in the blanks if no problems are observed. |
|If problems are observed, write either NO or a description, as appropriate. |
| |
|1. LIPS |
| Habitual posture: |Closed | |Open | |
| Evidence of Cleft Lip or other structural problem: |Yes | |No | |
| Describe: | |
| Symmetrical appearance: |Yes | |No | |
| Describe: | |
| Mobility: |Presses | |Purses | |
| |Retracts | |Symmetrical movement | |
| |
|2. MANDIBLE |
| Mobility: |Sufficient | |Insufficient | |
| |
|3. TEETH |
|Condition: |WNL | |Excessive decay | |
|Spacing: |WNL | |Excessive spaces | |Crowded | |
|Missing teeth: |All present: | |Specify missing teeth | |
|Occlusion: |WNL | |Under bite | |Over bite | |
| Open bite _______________ |
|4. TONGUE |
|Carriage: |Normal | |Protruded | |
|Protrusion: |Deviation | |Tremors | |
|Mobility: |Elevation | |Lateralization | |
| |Licks in circular motion | |
| |Sweeps palate from alveolar ridge | |
| |Moves independently of jaw | |
|Lingual Frenulum: |Attached | |Unattached | |
| |
|PALATE |
|Hard Palate: |Normal | |Cleft | |Describe | |
|Contour: |Normal | |Flat | |Deep/Narrow | |
|Velum:: |Normal | |Cleft | |Describe | |
| |Length: | |Satisfactory | |Short | |
| |Mobility: | |Adequate | |Inadequate | |
|Uvula: |Normal | |Deviated | |Bifed | |
|Tonsils: |Normal | |Enlarged | |Removed | |
| |
| |
|Speech-Language Pathologist: | |
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