PROFORMA FOR FLUENCY DISORDERS

Name: Client.No: Date:

Age/Gender: Student clinician: Informant:

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:

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