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FORM 6-1.: Oral-facial Examination Form (Lamar University)

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FORM 6-1.
Oral-facial Examination Form
Name: ____________________________________________________ Age: ______ Date: _____________
Examiner: ________________________________________________________________________________
Instructions: Check and circle each item noted. Include descriptive comments in the right-hand margin.
Evaluation of Face Comments
_______ symmetry: normal/droops on right/droops on left _________________________________________
_______ abnormal movements: none/grimaces/spasms ____________________________________________
_______ mouth breathing: yes/no _____________________________________________________________
_______ other: ___________________________________________________________________________
Evaluation of Jaw and Teeth
Tell client to open and close mouth.
_______ range of motion: normal/reduced ______________________________________________________
_______ symmetry: normal/deviates to right/deviates to left ________________________________________
_______ movement: normal/jerky/groping/slow/asymmetrical ______________________________________
_______ TMJ noises: absent/grinding/popping __________________________________________________
_______ other: ____________________________________________________________________________
Observe dentition.
_______ occlusion (molar relationship): normal/neutroclusion (Class I)/ distoclusion (Class II)/ mesioclusion
(Class III)/ _______________________________________________________________________
_______ occlusion (incisor relationship): normal/overbite/underbite/crossbite __________________________
_______ teeth: all present/dentures/teeth missing (specify) _________________________________________
_______ arrangement of teeth: normal/jumbled/spaces/misaligned ___________________________________
_______ hygiene: _________________________________________________________________________
_______ other: ___________________________________________________________________________
Evaluation of Lips
Tell client to pucker.
_______ range of motion: normal/reduced ______________________________________________________
_______ symmetry: normal/droops bilaterally/droops right/droops left _______________________________
_______ strength (press tongue blade against lips): normal/weak ____________________________________
_______ other: ____________________________________________________________________________
Assessment in Speech-Language Pathology: A Resource Manual, Third Edition
Copyright © 2004 Delmar Learning. All rights reserved. Permission to reproduce for clinical use granted.
FORM 6-1. Continued
Tell client to smile.
_______ range of motion: normal/reduced ______________________________________________________
_______ symmetry: normal/droops bilaterally/droops right/droops left _______________________________
_______ other: ___________________________________________________________________________
Tell client to puff cheeks and hold air.
_______ lip strength: normal/reduced _________________________________________________________
_______ nasal emission: absent/present ________________________________________________________
_______ other: ___________________________________________________________________________
Evaluation of Tongue
_______ surface color: normal/abnormal (specify) _______________________________________________
_______ abnormal movements: absent/jerky/spasms/writhing/fasciculations ___________________________
_______ size: normal/small/large _____________________________________________________________
_______ frenum: normal/short _______________________________________________________________
_______ other: ___________________________________________________________________________
Tell client to protrude the tongue.
_______ excursion: normal/deviates to right/deviates to left ________________________________________
_______ range of motion: normal/reduced ______________________________________________________
_______ speed of motion: normal/reduced ______________________________________________________
_______ strength (apply opposing pressure with tongue blade): normal/reduced ________________________
_______ other: ___________________________________________________________________________
Tell client to retract tongue.
_______ excursion: normal/deviates to right/deviates to left ________________________________________
_______ range of motion: normal/reduced ______________________________________________________
_______ speed of motion: normal/reduced ______________________________________________________
_______ other: ___________________________________________________________________________
Tell client to move tongue tip to the right.
_______ excursion: normal/incomplete/groping _________________________________________________
_______ range of motion: normal/reduced ______________________________________________________
_______ strength (apply opposing pressure with tongue blade): normal/reduced ________________________
_______ other: ___________________________________________________________________________
Assessment in Speech-Language Pathology: A Resource Manual, Third Edition
Copyright © 2004 Delmar Learning. All rights reserved. Permission to reproduce for clinical use granted.
FORM 6-1. Continued
Tell client to move the tongue tip to the left.
_______ excursion: normal/incomplete/groping _________________________________________________
_______ range of motion: normal/reduced ______________________________________________________
_______ strength (apply opposing pressure with tongue blade): normal/reduced ________________________
_______ other: ___________________________________________________________________________
Tell client to move the tongue tip up.
_______ movement: normal/groping __________________________________________________________
_______ range of motion: normal/reduced ______________________________________________________
_______ other: ___________________________________________________________________________
Tell client to move the tongue tip down.
_______ movement: normal/groping __________________________________________________________
_______ range of motion: normal/reduced ______________________________________________________
_______ other: ___________________________________________________________________________
Observe rapid side-to-side movements.
_______ rate: normal/reduced/slows down progressively __________________________________________
_______ range of motion: normal/reduced on left/reduced on right __________________________________
_______ other: ___________________________________________________________________________
Evaluation of Pharynx:
_______ color: normal/abnormal _____________________________________________________________
_______ tonsils: absent/normal/enlarged _______________________________________________________
_______ other: ___________________________________________________________________________
Evaluation of Hard and Soft Palates:
_______ color: normal/abnormal _____________________________________________________________
_______ rugae: normal/very prominent ________________________________________________________
_______ arch height: normal/high/low _________________________________________________________
_______ arch width: normal/narrow/wide ______________________________________________________
_______ growths: absent/present (describe) _____________________________________________________
_______ fistula: absent/present (describe) ______________________________________________________
_______ clefting: absent/present (describe) _____________________________________________________
_______ symmetry at rest: normal/lower on right/lower on left _____________________________________
Assessment in Speech-Language Pathology: A Resource Manual, Third Edition
Copyright © 2004 Delmar Learning. All rights reserved. Permission to reproduce for clinical use granted.
FORM 6-1. Continued
_______ gag reflex: normal/absent/hyperactive/hypoactive ________________________________________
_______ other: ___________________________________________________________________________
Tell client to phonate using /ɑ/.
_______ symmetry of movement: normal/deviates right/deviates left _________________________________
_______ posterior movement: present/absent/reduced _____________________________________________
_______ lateral movement: present/absent/reduced _______________________________________________
_______ uvula: normal/bifid/deviates right/deviates left ___________________________________________
_______ nasality: absent/hypernasal ___________________________________________________________
_______ other: ____________________________________________________________________________
Summary of Findings:
Assessment in Speech-Language Pathology: A Resource Manual, Third Edition
Copyright © 2004 Delmar Learning. All rights reserved. Permission to reproduce for clinical use granted.
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FORM 6-1.: Oral-facial Examination Form (Lamar University)

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Completed 18 September 2020

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