ORAL FACIAL EXAM CHECKLIST

Name: DoB: Date: Examiner:

Structure Assessed Circle Description

CN V TRIGEMINAL (MOTOR)
Mouth Opening WNL Deviation R/L
Mouth Opening w/resistance WNL Weakness
Jaw side to side WNL R only /L only
Clench your teeth WNL Weak R/ L
CN V Trigeminal (Sensory) *CHECKING GROSSLY FOR TOUCH
“Close your eyes and tell me where I am touching.” (check bilateral sensation as you touch areas on their face)

Forehead WNL Decreased R/L

Cheek WNL Decreased R/L
Jaw WNL Decreased R/L
CN VII FACIAL (MOTOR) *OBSERVE ALL FOR SYMMETRY AND MOVEMENT
Sit and look straight ahead WNL Eye droop Tremors Tics Lip corner droop Drooling Asymmetry Mask-like face
Wrinkle your forehead WNL Deviation R/L
Close your eyes tightly WNL Deviation R/L
Pucker your lips WNL Droop R/L

Smile WNL Deviation R/L

Teeth while frowning WNL Deviation R/L
“Say /pu pu pu/" WNL Deviation
CN IX AND X GLOSSOPHARYNGEAL AND VAGUS (MOTOR)
Open mouth (soft palate at rest) WNL Lower R/L arch
“Say ah” (soft palate movement) WNL No elevation R/L Deviation of uvula to R/L
“Say “ahhh” (long as possible) WNL Abnormal voicing Hoarse Breathy Weak Cough No cough reflex
CN XII HYPOGLOSSAL (MOTOR)
Open mouth (tounge at rest) WNL Atrophy R/L Fasciculations
Stick out your tongue WNL Deviation R/L Unable to protude past lips
Tongue (back of throat) WNL Unable to draw tongue base up or back Unable to retract and depress
Tongue (side to side) WNL Inability to move R/L
Tongue (strength) WNL Weakness
Tongue (strength manipulation) WNL Decreased tone (flaccidity) Increased tone (spasticity)
CN XI SPINAL ACCESSORY (MOTOR)
Maintain turn head posistion w/resistance WNL Weakness R/L
Push head foward w/resistance WNL Unable
Shrug your shoulders (symmetry) WNL Unable
 COMMUNICATION CHECKLIST

Name: DoB: Date: Examiner:

AUDITORY COMPREHENSION & INFORMATION PROCESSING

Understanding words and sentences Integrating information Shifting attention from one speaker to another
Understanding complex statements (humour, subtle, implied information) Understanding long statements (discussions, lectures, news, TV)
Tendency to misunderstand or misinterpret discussions Focusing attention on what is said (distraction, fatigue, interest)
Staying on track with the conversation, staying on topic Remembering new conversations, events, new information

Following step directions

EXPRESSION, DISCOURSE & SOCIAL COMMUNICATION

Nonverbal skills (eye contact, personal space, facial expression, tone of voice, mannerisms, gestures)
Generating topics of conversation, thinking of what to say, elaborating, adding Sentence planning, sentence construction, grammar
Overly talkative, rambling, verbose conversation Initiating conversation
Word finding, word retrieval, thinking of the word, vocabulary, word choice Speech sounds, muscle movements, voice, fluency, stuttering
READING COMPREHENSION
Decoding letters or words, reading aloud fluently Comprehending read sentences, paragraphs, text

Attending to what is read, need to read everything twice Reduced stamina for reading (Reads for ____min now; ____min prior to onset)
THINKING, REASONING, PROBLEM SOLVING, EXECUTIVE FUNCTIONS, SELF-REGULATION

Insight, awareness, recognizing there is a problem Discussing without being overwhelmed, upset, withdrawn
Organizing, integrating, analyzing, inferring, seeing the whole picture Summarizing, getting the gist or the bottom line, drawing conclusions