PROFORMA FOR CLEFT PALATE Name:
Client.No:
Date:
Age/Gender:
Student clinician:
Informant:
Mother tongue:
Chief complaint: Onset/Nature of the problem: Cleft type: Birth History: Pre-natal: Peri-natal: Post-natal:
Family History: Feeding habits:
Vegetative skills:
Medical history:
Surgical history: (a) Repair of lip: (b) Repair of palate: Other management: (a) Prosthodontic: (b) Orthodontic: 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:
Scholastic performance:
OSME:
Speech skills: Respiration: Phonation: Articulation: Resonation:
normal/ mild/ moderate/ severe
Test administered: Findings: DDK: Intelligibility rating: (a)
Word level:
(b)
Sentence level:
Stimulability: Rate of speech: Prosody:
Language skills: Speech and language stimulation at home: Language exposed to:
Comprehension:
Expression:
Language test Results:
3 point scale/ 5 point scale
Auditory/Visual/Kinesthetic
Secondary language skills: Reading:
Writing:
Provisional diagnosis:
Recommendation:
Signature of staff: KUNNAMPALLIL GEJO JOHN