AARUPADAI VEEDU MEDICAL COLLEGE & HOSPITAL

DEPARTMENT OF AUDIOLOGY AND SPEECH LANGUAGE PATHOLOGY

Pre-Therapy Assessment for Child Language Disorder

NAME: DATE:

AGE/SEX: D.O.B:

PROVISIONAL DIAGNOSIS:

DAYS AND TIMINGS OF THERAPY:

NO. OF SESSION PER WEEK: INTERVENTION INTENSITY:

CLINICAL SUPERVISOR: STUDENT CLINICIAN:

BRIEF HISTORY:

SPEECH MILESTONES:

DIFFERENTIAL CRY:

COOING:

BABBLING:

JARGON SPEECH:

FIRST WORD UTTERANCE:

ONE WORD UTTERANCES:

MOTOR MILESTONES:

NECK CONTROL:
TURN OVER:

CRAWLING:

SITTING WITH SUPPORT:

SITTING WITHOUT SUPPORT:

STANDING WITH SUPPORT:

STANDING WITHOUT SUPPORT:

WALKING WITH SUPPORT:

WALKING WITH OUTSUPPORT:

SOCIAL AND BEHAVIOURAL SKILLS:

OPME EXAMINATION:

STRUCTURE FUNCTION
LIPS
TEETH
ALVEOLAR
PALATE
VELUM
UVULA
TOUNGE
MANDIBLE
MAXIILLA
IMPRESSION:
SENSORY SKILLS:

VISION:

AUDITION:

TEST ADMINISTERED:

SPEECH AND LANGUAGE PROFILE:

MODE OF COMMUNICATION:

RECEPTIVE SKILLS:

EXPRESSIVE SKILLS:
LINGUISTIC SKILLS:

PHONOLOGY:

MORPHOLOGY & SYNTAX:

SEMANTICS:

PRAGMATICS:
RECOMMENDATIONS :

LONG TERM GOAL:

SHORT TERM GOALS:

1.

2.

3.

4.

5.

6.