SPEECH-LANGUAGE EVALUATION REPORT

Patient: [Name]
Date of birth: [Date]
Age at evaluation: [Years and months]
Date of evaluation: [Date]
Referred by: [Name and role]
Languages: [Languages used at home, school, or work; interpreter used or not]
Evaluator: [Name, credentials]

BACKGROUND
Reason for referral: [The referral question and main concerns, in the family's or patient's words]
Medical history: [Diagnoses, neurological events, hospital stays, medications]
Development or prior function: [Milestones for a child; communication and swallowing before the illness for an adult]
Education or work: [School placement and supports, or occupation]
Previous services: [Earlier therapy, and the outcome]

HEARING AND ORAL MECHANISM
Hearing: [Screening result today, or the latest audiology result, and any devices]
Oral mechanism: [Structure and function of lips, tongue, jaw, palate, and teeth; diadochokinetic rates]

STANDARDIZED TESTS
Tests given: [Full name and edition of each test]
Scores: [Standard scores, percentile ranks, and confidence intervals where the manual gives them]
Validity: [Anything that limits the scores, such as attention, language background, norms, or changes to administration]

LANGUAGE
Receptive language: [Understanding of words, directions, sentences, and stories or conversation]
Expressive language: [Vocabulary, sentence structure, grammar, narrative, word finding]
Pragmatics: [Turn-taking, topic maintenance, repair]
Language sample: [Context, number of utterances, and key measures]

SPEECH
Articulation and phonology: [Sound errors, patterns, stimulability, intelligibility]
Fluency: [Type and frequency of disfluencies, secondary behaviors]
Voice and resonance: [Pitch, loudness, quality, resonance]
Motor speech: [Signs of dysarthria or apraxia of speech, or none]

SWALLOWING
Screening: [Swallowing screen or clinical swallow evaluation, or not assessed and why]
Findings: [Position, consistencies and how given, oral and pharyngeal signs, signs of aspiration]

IMPRESSIONS
Diagnosis: [Communication or swallowing diagnosis, with severity]
Supporting findings: [Scores and observations behind it]
Strengths: [What the patient does well]
Prognosis: [Prognosis for improvement, and what affects it]

RECOMMENDATIONS
Therapy: [Recommended or not; frequency, session length, setting, and duration]
Referrals: [Audiology, physician, instrumental swallowing study, or others]
Strategies: [For the family, teachers, or care staff]
Diet and safety: [Diet texture and liquid level, positioning, supervision, if swallowing was assessed]

GOALS
Long-term goal: [Functional outcome for the plan of care]
Short-term goal 1: [Behavior, condition, accuracy criterion, cue level, and time frame]
Short-term goal 2: [Behavior, condition, accuracy criterion, cue level, and time frame]
Discussed with: [Patient, family, or team, and their agreement with the plan]

Signed: [Clinician name, credentials, date and time]