Oral Motor Screening Checklist

Name: D.O.B.: Age: Examiner: Time: .

Date: / / Medical Diagnosis: Speech Diagnosis: .

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: _______________________

Ask patient to open and close mouth.

A. Range of motion:
Within normal limits Groping
Reduced. Slow
Other: _______________________ Asymmetrical
B. Symmetry: Other: _______________________
Jaw Within normal limits D. Temporomandibular joint noises:
Functions are carried by Deviated to the right/left Absent
V: trigeminal nerve
Other: _______________________ Grinding
C. Movement: Popping
Within normal limits Other: _______________________
Jerky

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: ___________________________

Lateral view of Lateral view of

central incisor first molar

© Aljawharh AlOlayan, Nourah AlSheraim, Raghad AlMuaqel, Shahd AlMuqbil. Supervised by: Nora Fahad AlSudairi, 2015. 1/2
 Oral Motor Screening Checklist

Ask patient to open mouth:

A. Tongue at rest: F. Strength (apply opposing pressure with tongue depressor):
Within normal limits Within normal limits
Deviated towards the right/left Reduced
B. Abnormal movement: Other: ___________________________
Jerky Ask patient to:
Spasms A. Move the tongue tip to the right:
Writhing WNL* Reduced Other
Fasciculation B. Move the tongue tip to the left:
Other: ___________________________ WNL Reduced Other
C. Size: C. Move the tongue tip up:
Within normal limits WNL Reduced Other
Microglossia D. Move the tongue tip down:
Tongue Macroglossia WNL Reduced Other
Functions are carried by Other: ___________________________ E. Draw the tongue tip along the hard palate:
XII: Hypoglossal Nerve D. Color: WNL Reduced Other
XI: Accessory Nerve
Within normal limits Observe rapid side-to-side movements.
Bluish A. Rate:
Greyish Within normal limits
White spots Reduced
Other: ___________________________ Slows down progressively
E. Lingual frenum: Other: ___________________________
Within normal limits B. Range of motion:
Short (Ankyloglossia) Within normal limits
Other: ___________________________ Reduced on the right/left
Other: ___________________________
*WNL: Within normal limits

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