Print Form

INDEPENDENT LIVING, INC.- PEDIATRICS

6508 GUNN HIGHWAY TAMPA, FL 33625
(813) 963-6923 FAX (813) 274-0768

Oral Motor Examination Tool

Client’s Name: _________________________ D. O. B.: ________ Age: _____ Date of Exam: ___________
Examiner: _________________________
Scoring Key: +: Appropriate box NT: Not Tested NR: No Response L/R (circle affected side)
I. Face:
At rest: (required)
Symmetry: _____Yes _____No ( L / R ) Any apparent paralysis: _____Yes _____No ( L / R)
Other:__________________________________________________________________

Imitation: (If unable to imitate, go to passive range of motion)

Wrinkle forehead: _____Yes _____No Grimace: ___ Yes ___No

Passive Range of Motion/Strength:

Upper Cheek ROM: (Right) _____Yes _____No (Left) _____Yes _____No
Lower Cheek ROM: (Right) _____Yes _____No (Left) _____Yes _____No
Posterior Cheek Strength: (Right) _____Yes _____No (Left) _____Yes _____No

II. Lips:
At rest: (required)
Symmetry: ___Yes ___No ( L / R ) Closure: ___Yes ___No
Lips Retracted: ___mild ___moderate ___severe Upper lip tone: ___increased ___decreased _ _normal
Lips Pursed: ___mild ___moderate ___severe Lower lip tone: ___increased ___decreased ___normal
Drooling: ___mild ___moderate ___severe Tremor: ___Yes ___No
Deviancies: ___Scar ___Cleft ( unilateral / bilateral )
Other:__________________________________________________________________

Imitation: (If unable to imitate, go to passive range of motion)

Movements are symmetrical: ___Yes ___No (L / R) Round lips: ___Yes ___No
Draw corners back: ___Yes ___No Open and close lips: ___Yes ___No
Close lips, puff cheeks: ___Yes ___No Bite lower lip: ___Yes ___No
Move mouth side to side: ___Yes ___No Resistance: ___Yes ___No
( __Mild __Moderate __Severe )

Passive Range of Motion/Strength:

Upper Lip ROM: Lower Lip ROM:
Protrusion: _____Yes _____No Protrusion: _____Yes _____No
Elongation: _____Yes _____No Elongation: _____Yes _____No
Upper Lip Strength: Lower Lip Strength:
Right: _____Yes _____No Right: _____Yes _____No
Center: _____Yes _____No Center: _____Yes _____No
Left: _____Yes _____No Left: _____Yes _____No
Other: ___________________________________________________________________

III. SOFT PALATE / PHARYNX :

At rest: (required)
Symmetry: ___Yes ___No ( L / R ) Uvula: ___Bifurcated ___Asymmetrical ( L / R )
___Normal
Palatine Tonsils: ___Yes ___No Cleft: ___Yes ___No ( unilateral / bilateral )
Imitation:
Vertical movement (sustained /a/): ___Yes ___No Symmetry: ___Yes ___No
Lateral movement (sustained /a/): ___Yes ___No Symmetry: ___Yes ___No
 Name: __________________________D.O.B. ___________
IV. Tongue:
At rest: (required)
Deviates: ___Yes ___No ( L / R ) Size: ___Too large ___Too small ___Normal
Tone: ___Increased ___Decreased ___Normal Frenum: ___Normal ___Short/tight
Surface: ___Fasciculations ___Atrophy ___Flat ___Thick ___Bunched
Resting Position: ___Protruded outside mouth ___Retracted ___Midline
Other: ________________________________________________________________
Imitation: (If unable to imitate, go to passive range of motion)
Protrusion: ___Yes ___No ___Thrusting ___Exaggerated protrusion ___Reduced protrusion ___Asymmetrical
Retraction: ___Yes ___No Lateralization: (Right) ___Yes ___No (Left) ___Yes ___No
Tip elevation: ___Yes ___No Tip drawn back along hard palate: ___Yes ___No
Tip depression: ___Yes ___No Moves tongue independently of jaw:___Yes ___No
Back elevation: ___Yes ___No Resistance: ___Yes ___No ( ___Mild ___Moderate ___Severe )
Cupping: ___Yes ___No
Passive Range of Motion/Strength:
Tongue moves toward pressure applied to the gums: ___Yes ___No
Body of the tongue moves toward:
Lower lateral gum: (Right) _____Yes _____No (Left) _____Yes _____No
Cheek: (Right) _____Yes _____No (Left) _____Yes _____No
Upper lateral gum: (Right) _____Yes _____No (Left) _____Yes _____No
Midblade elevation: ___Yes ___No
Tongue tip elevation: ___Yes ___No

V. Jaw:
At rest: (required)
Size: ___Too large ___Too small ___Normal Protruded: ___Yes ___No
Clenched (tonic bite reflex): ___Yes ___ No Retracted: ___Yes ___No
Class of occlusions:
____Normal occlusion
____Distoclusion (Maxilla protruded anteriorly, mandible retruded posteriorly)
____Mesioclusion (Maxilla retruded posteriorly, mandible protruded anteriorly)
Dentition:
____Openbite (Upper incisors do not cover lower incisors)
____Closebite (Upper incisors cover more than 1/3 of lower incisors)
____Overbite (Upper incisors too far anterior relative to lower incisors)
____Underbite (Upper incisors posterior to lower incisors)
____Endentulous spaces
____Proximal contact
Condition of teeth: ____Good ____Poor ____Missing teeth
Other:__________________________________________________________________
Imitation:
Graded opening: ___Wide ___Restricted ( L / R) ___Normal Lateralization: ___Yes ___No
Protrusion: ___Yes ___No Resistance: ___Yes ___No
Jaw thrust: ___Yes ___No Jaw Clicks: ___Yes ___No

VI. Hard Palate:

At rest: (required)
Vault Height: ___Too High ___Too low ___Normal Vault Width: ___Too Wide ___Too narrow ___Normal
Cleft: ___Yes ___No ( unilateral / bilateral )
Other:__________________________________________________________________

VII. DIADOCHOKINESIS: (see norms sheet):

1. p^p^p^ (20 times)/______seconds. Rhythmic: ___Yes ___No Articulation Accurate: ___Yes ___No
2. t^t^t^ `` (20 times)/______seconds. Rhythmic: ___Yes ___No Articulation Accurate: ___Yes ___No
3. k^k^k^ (20 times)/______seconds. Rhythmic: ___Yes ___No Articulation Accurate: ___Yes ___No
4. p^t^, p^t^, p^t^ (10 times)/______seconds. Rhythmic: ___Yes ___No Articulation Accurate: ___Yes ___No
5. p^t^k^, p^t^k^, p^t^k^ (10 times)/______seconds. Rhythmic: ___Yes ___No Articulation Accurate: ___Yes ___No
Comments:
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