Speech and Language Assessment Performa
1. Demographic Information
Name of the Client:
Age/Date of Birth:
Gender:
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Male
Female
Other
Address:
Contact Information:
Referred By:
Date of Assessment:
2. Family History
Family Composition:
Languages Spoken at Home:
History of Speech, Language, or Hearing Disorders in Family:
Choose...
Yes
No
If Yes, specify in the comments below.
Relevant Medical or Genetic Conditions in Family:
Parental Occupation and Education Level:
4. Vegetative Skills
Feeding Issues:
Chewing:
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Normal
Difficulty
Swallowing:
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Normal
Difficulty
Drooling:
Choose...
Yes
No
Breathing Pattern:
Choose...
Nasal
Mouth Breathing
Oral Habits:
5. Orofacial/Oral Peripheral Mechanism Examination
Structure and Function of Oral Structures:
Reflexes:
6. Hearing Evaluation
Hearing History:
Hearing Screening Results:
7. Pre-Requisite Learning Skills
Attention and Concentration:
Eye Contact:
Choose...
Adequate
Inadequate
Imitation Skills:
Turn-Taking Abilities:
Choose...
Yes
No
8. Social Skills
Interaction with Peers and Adults:
Non-Verbal Communication:
Ability to Share and Cooperate:
9. Assessment Tools Used
Assessment of Language Development (ALD):
Other Tools (MAT, SSI, OPT, etc.):
10. Summary of Findings and Recommendations
Strengths Identified:
Areas of Concern:
Therapeutic Goals:
Referrals (if any):
11. Recommendations
Therapeutic Goals:
Frequency and Duration of Therapy:
Referrals (if any):