PROFORMA FOR DELAYED SPEECH AND LANGUAGE

Name: Age/Gender: Mother tongue:

Client No: Student clinician:

Date: Informant:

Chief complaint: Onset/Nature of the problem:

Birth History:
Pre-natal:

Peri-natal:

Post-natal:

Family History:
Consanguinity: Sibling History: Nuclear/Joint Family: Any other:

Medical History:

Developmental History:
1. Motor milestones: a) Head control: b) Turning over: c) Crawling: d) Sitting with support: e) Sitting without support: f) Standing with support: g) Standing without support: h) Walking with support: i) Walking without support: j) Bowel & bladder control: 2. Social development: a) Social smile: b) Recognition of mother: c) Discrimination of strangers: d) Solo play: e) Group play: 3. Sensory development: Hearing/ Sensory

4. Language development:

a) Babbling: b) First word: c) Phrases & sentences:

Speech & language skills:

a) Oral Speech Mechanism Examination:

b)

Vegetative functions:

c)

Speech skills:

d)

Language skills:

Mode of communication:

Regression, if any:

Languages exposed to: Comprehension:

Expression:

Language test Results:

Behavioral deviations, if any:

Education:
Regular/special:

Age of entry:

Performance at school:

Reading skills:

Writing skills:

Provisional Diagnosis:

Recommendation:
Signature of the Staff: KUNNAMPALLIL GEJO JOHN