LocuTour's Oral-Peripheral Evaluation Checklist

The following checkboxes are available to assist in the initial evaluation of the client.

Oral-Peripheral Evaluation—Face
Face
A: The oral-peripheral evaluation indicated that the face was:
Symmetrical- Normal
Asymmetrical and droops to the right
Asymmetrical and droops to the left
Other Observations: __________________

Movement/ Breathing
A: The following movement/ breathing patterns were also observed:
Normal
Grimaces/ abnormal movements/ tics
Mouth breathing
Audible inspiration
Tongue protrusion
Labored breathing
Other Observations: __________________

Tone
A: The facial tone was:
Normal
Flaccid
Mask-like
Tense
Other Observations: __________________

Lips - Protrusion
A: Lips for a pucker (Protrusion) was:
Symmetrical (even) Normal
Asymmetrical (uneven) with a weakness on right (unilateral)
Asymmetrical (uneven) with a weakness on left (unilateral)
Asymmetrical (uneven) with a bilateral droop
Other Observations: __________________

Lips - Retraction
A: Lips for a smile (Retraction) was:

Symmetrical (even) - Normal

Asymmetrical (uneven) with a weakness on right (unilateral)
Asymmetrical (uneven) with a weakness on left (unilateral)
Asymmetrical (uneven) with a bilateral droop
Other Observations: __________________

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 LocuTour's Oral-Peripheral Evaluation Checklist
Lips - strength
A: When asked to puff cheeks and hold air the lip strength was:
Normal
Weak/ reduced/ air escaped
Other Observations: __________________
Normal

Nasal emission
A: Nasal emission was:
Normal- not present
Abnormal- nasal emission present
Other Observations: __________________
Drooling
A: Drooling was:
Absent - Normal
Present - Constant
Present - Intermittent
Other Observations: __________________

Oral-Peripheral Evaluation—Teeth
Teeth
A: The Teeth were:
Normal
Missing/ Edentulous -- ___ teeth present
Jumbled/ spaces/ misaligned/ crowded teeth
Chewing surfaces were adequate for all food textures
Chewing surfaces were inadequate for some food textures
Other Observations: __________________

Occlusion
A: The Occlusion appeared to:
be Normal - molars touch
have an Underbite
have an Overbite
have a Crossbite
Other Observations: __________________

Dentures
A: The client wears dentures,
they fit well
they don't fit well
and client consistently wears them
and client doesn't consistently wear them
Other Observations: __________________

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 LocuTour's Oral-Peripheral Evaluation Checklist
Oral Hygiene
A: The client's Oral Hygiene:
is Normal and independent
Requires assistance
is Poor and may contribute to poor health
Other Observations: __________________

Mucosa
A: The client's Mucosa
is Healthy – gingiva (scalloped, firm, knife-like margins, stippled texture)
is Diseased gingiva (inflammation, rolled margins, no stippling, gingiva is erythematous,
edematous and/or painful)
Other Observations: __________________

Saliva
A: The client's Saliva
is Healthy – watery, clear
is Diseased – thick, discolored - yellow, green, black, red
is Absent - xerostomia – dry mouth – painful mouth
Other Observations: __________________

Oral-Peripheral Evaluation—Jaw
Mandibular Movement
A: The evaluation of Mandibular Movement for:
Range of Motion
was Normal
was Reduced
Symmetry of Jaw
was Normal
Deviates to the right
Deviates to the left
Movement of Jaw was
Normal
Jerky
Groping
Slow
Asymmetrical

Tempromandibular Joint
A: Tempromandibular Joint (TMJ) Noises
were Absent - Normal
included Grinding and/or Popping

Other Observations of the jaw:

__________________

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 LocuTour's Oral-Peripheral Evaluation Checklist
Oral-Peripheral Evaluation—Palate
A: Evaluation of the Hard and Soft Palate indicated:
Color
Normal color
Abnormal color
Arch
Normal arch
High arch
Low arch
Wide arch
Narrow arch
Growths
No growths
Growths present
Location of growths ______
Fistula
No fistulas
Fistulas present
Location of fistulas ______

Cleft
No clefts
Repaired clefts
Location of repaired clefts ______
Unrepaired clefts present
Location of unrepaired clefts ______

A: Soft Palate symmetry at rest was:

Normal (symmetrical) soft palate symmetry at rest
Bifid soft palate symmetry at rest
Asymmetrical uvula deviates to the right
Asymmetrical uvula deviates to the left

A: Soft Palate symmetry on "Ah" was:

Normal (symmetrical) soft palate symmetry on “Ah”
Asymmetrical uvula deviates to the right on “Ah”
Asymmetrical uvula deviates to the left on “Ah”

A: Nasality was:
Normal
Hypernasal
Hyponasal

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 LocuTour's Oral-Peripheral Evaluation Checklist
A: Gag Reflex was:
Normal
Hyperactive
Hypoactive
Absent

A: Other Observations of the palate:

__________________

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 LocuTour's Oral-Peripheral Evaluation Checklist
Oral-Peripheral Evaluation—Tongue
A: Evaluation of the tongue indicated:
Tongue Size
Normal tongue size
Large tongue size
Small tongue size
Tongue Tone
Normal tongue tone
Flaccid tongue tone
Fasciculations/spasms/writhing movements of the tongue
Color and Texture
Normal color and texture
Coated
Grooved
White
Red
Ulcerated
Pierced
Bifurcated
Tongue
A: The client's Tongue
is Healthy – (pink, moist)
is Diseased - ( coated, blistered, cracked, ridged)
is often protruding with open-mouth breathing
is protruding because of enlarged Adenoids
Other Observations: __________________

Lingual Frenulum (the tissue that attaches the tongue to the fl oor of the mouth)
Normal frenulum
Short frenulum - Tongue cannot protrude past lips
Surgical history of frenulum: ________________
Bifurcated frenulum

A: Movement of the Tongue—Vertical (up/down) indicated:

Normal range, movement, and speed
Cannot move tongue tip up
Cannot move tongue tip down
Can move, but groping observed
Limited range
Limited speed

© 2010 LocuTour Multimedia, Inc. All Rights Reserved. For more info: 800-777-3166 or www.LocuTour.com
 LocuTour's Oral-Peripheral Evaluation Checklist
A: Movement of the Tongue—Horizontal (right/left) indicated:
Normal range, movement, and speed
Cannot move tongue tip right
Cannot move tongue tip left
Can move, but groping observed
Limited range
Limited speed

A: Movement of the Tongue—Protrusion/Retraction (in/out) indicated:

Normal range, movement, and speed
Cannot move tongue tip out
Cannot move tongue tip in
Can move, but groping observed
Limited range
Limited speed
Limited strength
Bifurcates on protrusion

A: Other Observations of the tongue:

________________________
Insufficient movement to remove food particles from mouth
Tongue motility problems contribute to oral stage dysphagia

Tension Sites
Tension Sites
A: Musculature tension was evaluated at the following sites:
Face
Facial tension present
Facial tension absent
Mandible
Mandible tension present
Mandible tension absent
Neck
Neck tension present
Neck tension absent
General Body
General body tension present
General body tension absent

A: Other Observations of Tension Sites:

________________________

© 2010 LocuTour Multimedia, Inc. All Rights Reserved. For more info: 800-777-3166 or www.LocuTour.com