Structural-Function Examination Form

Name:_________________________ Age:______________ Date:__________

Examiner:______________________

Instructions: Check and circle each item noted. Included descriptive comments in the right-hand margin.

Evaluation of Face

_____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/neutrolclusion (Class I)/distoclusion (Class II)/ mesiocluesion (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:____________________________________________________________________

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:______________________________________________________________________

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: absent / present_________________________________________________________

_____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_________________________________

_____gag reflex: normal / absent / hyperactive / hypoactive___________________________________

_____other:______________________________________________________________________

Tell client to phonate using /a/.

_____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:

 

 

 

 

 

 

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