ALI YAVARJUNG NATIONAL INSTITUTE OF SPEECH AND

HEARING DISABILITIES(DIVYANGJAN), NOIDA (U.P.)- 201301

SUMMARY REPORT

NAME: SEX/AGE: CASE NO:

DEVELOPMENTAL
REFERRED BY:
HISTORY
cOMPLAINT:
EDUCATIONAL
MEDICAL HISTORY: HISTORY:
FAMILY HISTORY:
AUDIOLOGICAL EVALUATION
125 250 500 1000 2000 4000 8000 12000

INFORMAL SCREENING: 20

FINDINGS:
S0

50

HEARING AID:
30
90
100
110
EARMOULD: 120
750 1500 30 b000 10000

Frequency in Hz

SPEECH &LANGUAGE EVALUATION

SPEECH MECHANISM:

FINDINGS:
 PSYCHOLOGICAL EVALUATION
CLINICAL OBSERVATIONS

ATTENTION-cONCENTRATION: GLOBAL DEVELOPMENT

QuOTIENT:
|ADAPTIVE AGE/DO:

MENTAL AGE
GROSS MOTOR SKILLS/DO:
1.Q:
FINE MOTOR SKILLS/DO:
PERSONALITY/INTEREST:
VSUOMOTOR INTEGRATION:
LANGUAGE AGEIDO:
BEHAVIOUR PROBLEM IF
ANY:
PERSONAL SoGAL SKILLS/D0:
CLINICAL IMPERSSION:

MEDICAL EVALUATION

ENT PEDIATRICS NEUROLOGY

EDUCATIONAL &VOCATIONAL EVALUATION

PROVISIONAL DIAGNOSIS

RECOMMENDATIONS