PROFORMA FOR FLUENCY DISORDERS
Name:
Client.No:
Age/Gender:
Student clinician:
Mother tongue:
Presenting complaint:
Onset/Nature of the problem: Family history:
Reaction to the problem:
Variation in stuttering: Sound/ word/ language specificity:
Situation specificity:
Individual specificity:
Word position specificity:
Consistency in errors:
Anticipatory behaviour:
Avoidance behaviour:
Coping mechanism (if any):
OSME:
Date: Informant:
Language skills:
Secondary language skills:
Speech skills: Respiration: Phonation: Articulation: Prosody: Rate of speech: Intelligibility of speech:
Components of stuttering: Core behaviors:
Reading/conversation:
Secondary behaviors:
Feelings and attitudes:
Naturalness of speech:
Tests administered: Results:
Severity of the problem:
Previous history of treatment:
Provisional Diagnosis:
Recommendations:
Signature of the Staff: KUNNAMPALLIL GEJO JOHN