ࡱ>  Root Entry( Jr WMatOSTTV WMMMN0{ND ( JrMicrosoft Works MSWorksWPDoc9q LT {::PPPP!=/dPq t ORAL PERIPHERAL EXAMINATION SPEECH LANGUAGE SERVICES Department of Special Education/Sevier County Schools/Sevierville, TN Name _____________________________ Date _____________ Examiner ________________ LIPS: Habitual Posture: q Closed q Open Mobility: q Press q Purse q Retracts JAW MOBILITY: q Sufficient q Insufficient q Excessive TONGUE: Size: q Appropriate q Too large q Too small Frenum:q Normal q Short qClose to tip Habitual Posture: q Retracted q Protruded TONSILS/ADENOIDS: Removed? q Yes q No If yes, date __________ Size: q Normal q Abnormal LIPS-JAW-TONGUE DIFFERENTIATION: Response to verbal instructions or single imitative example: Score: 3=with ease; 2=with difficulty; 1=unable to do ___ Stick tongue out of mouth (no accompanying head movements or touching lips/teeth) ___ Elevate tongue tip (tip lifts independently, without overflow movements of head or jaw) ___ Do lateral wags (tongue moves independently through space, without jaw/head movements) ___ Retract tongue back to pharynx (back of tongue moves back; tip doesnt curl back) ___ Acquire lingual-palatal suction (firm palatal contact; makes a symmetrical tongue-pop) ___ Acquire taut, straight tongue (indicative of good lingual muscle tone and endurance) Total score: ____ Circle one: (15-18 within normal limits; 12-14 low normal; 12 and below, poor oral differentiation) Comments: _________________________________________________________________________ DENTITION: Dental Occlusion: q Normal Appearance q Abnormal Appearance If yes, complete below: __Overjet __Underjet __Openbite __Crossbite __Edge to edge __Wears Orthodontics PALATE: Hard Palate: q Normal q High Arch q Cleft Soft Palate: q Normal q Cleft Uvula: q Normal q Other ______________ SWALLOW: (overall) ___Normal swallowing pattern ___Abnormal swallowing pattern (If Yes, see below) ___Exhibits tongue thrust __Teeth are held apart __Inefficient intra-oral suctioning BREATHING: Mouth Breather? __Yes __No If yes, apparently due to: q habit q nasal obstruction ORAL HABITS: Thumb Sucking? __Yes __No Tongue Sucking? __Yes __No DIADOCHOKINESES: puh - q Adequate q Inadequate tuh - q Adequate q Inade (See instructions for assessment of rate.) kuh - q Adequate q Inadequate puhtuhkuh - q Adequate q Inadequate TACTILE SENSITIVITY: Firmly stroke face and neck with gloved hands or cloth, and oral areas with a tongue depressor, Toothette or Ora-Swab. a. Face and Neck __Normal __Hyper __Hypo b. Lips __Normal __Hyper __Hypo c. Gums and Inside of Cheeks __Normal __Hyper __Hypo d. Tongue Surtace (front) __Normal __Hyper __Hypo e. Tongue Surface (back) __Normal __Hyper __Hypo f. Hard Palate __Normal __Hyper __Hypo g. Soft Palate __Normal __Hyper __Hypo Tactile Acceptance: Weak 1 2 3 4 5 Defensive Comments: ________________________________________________________________________ __________________________________________________________________________________ 10/02 !; ")+24>M{uq{q{q{m{m{q{m{m{m{q(MQ_aqs~{w{w{wsw{w{w{wsw{w{w{w( .79>@CZ^begoq{{wswsw{wswswmw{wswsw{(Zef79;NPeuv{{u{o{u{u{k{g{g{u{u{(  )4689?ACHW{uqmuqumuqmu{uqumuqmu(W\]_agikE Q q {wqmwqmwq{wgw{wqwmw(      & ( ) , / 1 < > E o {wswsnw{w{wswnw{w{wh( (o p s v x H I {v{r{r{v{r{r{nh{hb((    $ & ysysyoio8 !;>~{u2qqkkkkeeeeeeeeeeeee !E'~NE E H | C yyyyyyyyyyyyyyyyyyyyyyy & ( yyyyyMW o  !"#$ %&'Times New Roman(P ZapfDingbats=/=/dCompObjU