SPEECH AND LANGUAGE ASSESSMENT PROFORMA

Name: --------------------------------------- Date: -----------------------------------

Age/ Sex: ----------------------------------- File No: --------------------------------
Father Name:------------------------------- Mother Name:-------------------------
Address:--------------------------------------------------------------------------------------
Telephone No:------------------------------
Siblings:-------------------------------------
Language Used: At Home :
At School:
At other situation:
Significant History :
Any other information :

1. Structure and Functions of Speech Mechanism

Structure Appearance Strength

Function Present Absent

Normal Abnormal

Face – Symmetry (Task)

Lips Normal / Abnormal At rest Protruding /u/

Retracting /e/

Tongue Normal /Abnormal At rest Pulling out

Taking Back
Lifting up
Moving to side

Hard palate Normal /Abnormal

Soft Palate Normal /Abnormal up/down movement

(Produce /p/and /m/)
2. Hearing screening check list :

Check Impression
Yes or No

i) At birth
a) Does your child awaken at loud sounds?
b) Does your child startle or cry at noises?
c) Does your child listen to speech?

ii) 3 Months
a) Does your child listen to soft sounds?
b) Does your child seem to recognize mothers voice?
c) Does your child stop playing and appear to listen to sounds or speech?
d) Does your child try to turn towards the speaker?

iii) 6 Months
a) Does your child respond t “ no” and her/ his name?
b) Does your child turn her/ his head toward the side where the sound is coming
from.

iv) 9 Months - 1 year

a) Does your child search or look around when hearing new sounds?
b) Does your child turn to look up when you call
c) Does your child respond to requests (come here, Do you want more)

v) 2 ½ years – 4 years
a) Does your child notice sounds (dog barking, telephone ringing television
sound, knocking at door and so on)
b) Does your child hear television or radio at the same loudness level as other
members of the family
c) Does your child hear you when you call from another room?

Instruction: Read each question through the child’s age group and check Yes or No.
If majority of the answers are “Yes”, the child is normal in hearing and if majority of the
answers are “No” refer the child to an Audiologist and Speech Pathologist.
 3. Language input to the child.

Parent - Child Interaction:

I. Quantity:
Time spent and the Frequent/ Occasional
Frequency with which the
Child is spoken to by
Caretakers.

II. Type of family Nuclear / Joint

III. Quality:
a) Type of sentence
Frequently used Questions Only Yes/ No
Commands only Yes/ No
Questions and Commands Yes/ No

b) Method employed General Conversation Yes/No

Narration task Yes/No
Story telling Yes/No

c) Frequent demand for during daily activities Yes/No

Correct Production of
Speech

IV. Any other information

V. Parent concern about child’s

Speech and language output Yes/No
 4. Content/ Language ability of the child

I. WORDS :
a) Nominal’s

Items Comprehension No. Of Items Expression No. Of Items

Food

Fruits

Clothing

Furniture

Parts of the body

Name of family members

Vehicles

Others

b) Action words :

Comprehension Expression
Items
Present Absent Not Sure Present Absent Not Sure

Sleeping

Sitting

Standing

Running

Jumping

Brushing

Hitting

Giving

Talking
Combing

Going

Pushing

Pulling

Dropping

Others

The exact word/words (or their examples ) comprehended or expressed. Should be

written down. This holds good for all subsequent areas under language content.

c) Pronouns:

Comprehension Expression
Items
Present Absent Not Sure Present Absent Not Sure

Me/I

Mine

You

Yours

He

His

She

Hers

They

Theirs

It
Its

d) Noun Modifiers:

Big

Small

Near

Far

Happy

Sad

Tall

Short

Good

Bad

Fat

Thin

Clean

Dirty

More

Little

e) Verb Modifiers
 Comprehension Expression
Items
Present Absent Not Sure Present Absent Not Sure

In

On

Under

Through

Beside

Between

Fast

Slow

Now

There

Here

Up

f) Connecting Words:

And

But

Or

Because

So
 So as to

Neither – Nor

Either

Later

Unless- Until

II. SEMANTIC INTENTIONS:

Comprehension
Expression
Items Present Absent Not
Present Absent Not Sure
Sure

Existence

Non- existence

Disappearance

Recurrence

Rejection

Denial

Location

Possession

Action

Attribution
Object

Agent

III. EARLY SENTENCES:

Expression
Items Examples
Present Absent Not Sure

Agent +Action

Action + Object

Agent +Location

Entity +Location

Possessor +Possession

Entity- Attribute

Demonstrative + Entity

IV. SENTENCE TYPE

Comprehension Expression
Items
Present Absent Not Sure Present Absent Not Sure

Declarative/ Statement

Negative - No

- No

- Can’t

Question

Yes/No
 Wh form

Yes/ No

Where

What

Which

When

How

Why

Complex/ Compound

Sentences

V. WORD ENDINGS (GRAMMATICAL MORPHEMES)

Comprehension Expression
Items
Present Absent Not Sure Present Absent Not Sure

Plurals

Present progressive

Past tense

Future tense

First person

Second person

Third person

Gender
 - Male

- Female

- Neuter

5. Language Use:

I. Mode of Expression :

a) Predominantly verbal

b) Predominantly non-verbal

c) Both

II. Mode of Expression

Types of errors Sounds Position in word

Second person Initial Medial Final

- Substitution

- Omission

- Distortion

- Addition

III. Intelligibility of Speech Good Fair Poor

IV. Usage Skills Present Absent Details

a. Beginning conversation

b. Turn taking

c. Ending conversation
V. Gestures :

a. Number of gestures used

b. Combination of gestures Present Absent Details

c. Gestures understood by
Good Fair poor
Others (intelligibility)