SLP - ORAL-PERIPHERAL EXAMINATION
STUDENT’S NAME:
DATE
SCHOOL:
DOB:
Write WNL or YES or a checkmark in the blanks if no problems are observed.
If problems are observed, write either NO or a description, as appropriate.
1.
LIPS
Habitual posture:
Closed
Open
Evidence of Cleft Lip or other structural problem:
Describe:
Symmetrical appearance:
Describe:
Mobility:
Presses
Retracts
2.
3.
4.
MANDIBLE
Mobility:
TEETH
Condition:
Spacing:
Missing teeth:
Occlusion:
Yes
Yes
No
No
Purses
Symmetrical movement
Sufficient
Insufficient
WNL
Excessive decay
WNL
Excessive spaces
Crowded
All present:
Specify missing teeth
WNL
Under bite
Over bite
Open bite _______________
TONGUE
Carriage:
Protrusion:
Mobility:
Normal
Protruded
Deviation
Tremors
Elevation
Lateralization
Licks in circular motion
Sweeps palate from alveolar ridge
Moves independently of jaw
Lingual Frenulum:
Attached
Unattached
5.
PALATE
Hard Palate:
Contour:
Velum::
Uvula:
Tonsils:
Normal
Normal
Normal
Length:
Mobility:
Normal
Normal
Speech-Language Pathologist:
Cleft
Flat
Cleft
Satisfactory
Adequate
Deviated
Enlarged
Describe
Deep/Narrow
Describe
Short
Inadequate
Bifed
Removed