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OME Screening Checklist 1697602735
OME Screening Checklist 1697602735
Structure Instructions: Check each item noted, circle each side as needed.
Symmetry at rest:
Within normal limits
Deviated towards the right/left
Face Droops* right/left
Functions are carried by
VII: Facial nerve Other: _______________________
*Droops: Bends or hangs downward.
Observe at rest.
A. Symmetry: B. Symmetry:
Within normal limits Within normal limits
Droops bilaterally/right/left Droops bilaterally/right/left
Other: ______________________ Other: _______________________
B. Drooling: Ask patient to puff cheeks and hold air.
Absent A. Lip’s strength:
Lips Present Within normal limits
Functions are carried by
Other: ______________________ Reduced
VII: Facial nerve Ask patient to smile. Other: _______________________
A. Range of motion: B. Nasal emission:
Within normal limits Absent
Reduced Present
Other: _______________________ Other: _______________________
Teeth:
All present
Dentures
Missing (circle the missing teeth)
Other: ___________________________
Type of occlusion: Deciduous teeth
Within normal limits
Permanent teeth
Malocclusion (overbite – crossbite – open bite – under bite)
Place of malocclusion if present: (right – left – bilateral)
Teeth Alignment of teeth: Illustrate the malocclusion
Within normal limits
Misaligned
Spaces (put arrows between teeth)
Other: ___________________________
© Aljawharh AlOlayan, Nourah AlSheraim, Raghad AlMuaqel, Shahd AlMuqbil. Supervised by: Nora Fahad AlSudairi, 2015. 1/2
Oral Motor Screening Checklist
Color:
Within normal limits Wide
Abnormal Other: ___________________________
Other: ___________________________ Fistula:
Arch height:
Absent
Within normal limits Present (describe in the comments section)
Hard Palate High Other: ___________________________
Low Cleft:
Other: ___________________________ Absent
Arch width: Present (describe in the comments section)
Within normal limits Other: ___________________________
Narrow
Soft palate symmetry at rest:
Within normal limits Deviated to the right/left
Lower on the right/left Other: ___________________________
Other: ___________________________ C. Nasality:
Gag reflex: Absent
Absent Hypernasality
Hyperactive Hyponasality
Hypoactive Other: ___________________________
Soft Palate Other: ___________________________ D. Breathing:
and Ask patient to phonate / ah /. Oral
Pharynx A. Soft palate movement: Nasal
Functions are carried by
IX: Glossopharyngeal Within normal limits E. Tonsils:
nerve
X: Vagus Nerve
Deviated to the right/left Within normal limits
XI: Accessory Nerve Palatal drop Absent
Other: ___________________________ Enlarged
B. Uvula: Other: ___________________________
Within normal limits
Bifid
Comments
Summery
© Aljawharh AlOlayan, Nourah AlSheraim, Raghad AlMuaqel, Shahd AlMuqbil. Supervised by: Nora Fahad AlSudairi, 2015. 2/2