SLI - 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. 	
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1.	LIPS	
	Habitual posture:  	 	Closed		Open  		
	Evidence of Cleft Lip or other structural problem:   	Yes		No  		
		Describe:		
	Symmetrical appearance:   	Yes		No		
		Describe:		
	Mobility:	Presses		Purses		
			Retracts		Symmetrical movement		
	
2.	MANDIBLE 	
	Mobility:	Sufficient		Insufficient		
	
3.	TEETH	
Condition:	WNL		Excessive decay		
Spacing:	WNL		Excessive spaces		Crowded		
Missing teeth:	All present:		Specify missing teeth		
Occlusion:	WNL		Distocclusion		Mesiocclusion		
	
4.	TONGUE	
Carriage:	Normal		Protruded		
Protrusion:	Deviation		Tremors		
Mobility:	Elevation		Lateralization		
  	Licks in circular motion		
	Sweeps palate from alveolar ridge		
	Moves independently of  jaw		
Lingual Frenulum: 	Attached		Unattached		
	
5.	PALATE	
Hard Palate:	Normal		Cleft		Describe		
Contour:	Normal		Flat		Deep/Narrow		
Velum::	Normal		Cleft		Describe		
	Length:		Satisfactory		Short		
	Mobility:  		Adequate		Inadequate		
Uvula:		Normal		Deviated		Bifed		
Tonsils:	Normal		Enlarged		Removed		
	
6.	____Oral structures and functioning appear normal. 

           ____Oral structures and functioning appear abnormal .
	
Speech-Language Pathologist: