SPEECH THERAPY ASSESSMENT REPORT
Personal Information
Name:
Age/Gender:
Date of Birth:
Location (Native):
Location (Abroad):
Languages Known:
Referrer:
Informant:
Mode of Consultation:
Date of Assessment:
Strengths of the Child
Areas of Concern
Reason for Referral
History
1. Birth History
2. Motor Developmental Milestones
3. Speech and Language Development Milestones
4. Family History
Family Composition:
Languages Spoken at Home:
History of Speech, Language, or Hearing Disorders in Family:
YES
NO
Relevant Medical or Genetic Conditions in Family:
Parental Occupation and Education Level:
Assessment Findings
1. Vegetative Skills
Feeding Issues:
Blowing:
Adequate
Inadequate
Chewing:
Adequate
Inadequate
Sucking:
Adequate
Inadequate
Swallowing:
Normal
Difficulty
Breathing Pattern:
Nasal Breathing
Mouth Breathing
Oral Habits:
2. Orofacial/Oral Peripheral Mechanism Examination
Structure and Function of Oral Structures:
3. Hearing Evaluation
4. Pre-requisite Learning Skills
Attention and Concentration:
Sitting Tolerance:
Present
Absent
Eye Contact:
Present
Absent
Imitation Skills:
Turn-Taking Abilities:
Present
Absent
Waiting Skills:
Present
Absent
5. Social Skills
Interaction with Peers and Adults:
Communication:
Verbal
Non-verbal
Ability to Share and Cooperate:
Assessment Tools Used
Assessment Tools:
Test Findings
Recommendation
Frequency and Duration of Therapy:
Referrals (if any):
Prepared by
Prepared by:
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