PROFORMA FOR CEREBRAL PALSY

Name: Age/Gender: Client No: Date: Informant: Mother tongue: Student clinician: Presenting complaint: Onset of the problem:

Birth History: Pre-natal: Peri-natal: Post-natal:

Family History: Medical History: Developmental History:

1. Motor milestones: Head control: Turning over: Crawling:

Sitting with support: Sitting without support: Standing with support: Standing without support: Walking with support:

Walking without support: Bowel & bladder control: 2. Sensory development: Hearing: Vision: 3. Language development: Vocalisations: Babbling: First word: Phrases & sentences:

Motor Behaviour: Muscle tone: Muscle control: Involuntary movement: Ambulatory skills: Co-ordination:

Speech Skills: Respiration: Phonation: Articulation:

Intelligibility: Parents Clinician Others

Word level Sentence level

DDK: Resonation: Prosody: Rate of speech:

Vegetative Skills: Sucking: Swallowing: Chewing:

Biting: Blowing: Drooling:

Reflexes: OSME:

Mode of communication: Language Skills: Comprehension:

Expression:

Languages exposed to/ languages known: Language Test Administered: Results:

Previous treatment taken:

Secondary Language Skills: Reading: Writing:

Scholastic Performance:

Cognitive Ability:

Associated problems if any: Provisional Diagnosis: Recommendations: Signature of staff:

KUNNAMPALLIL GEJO JOHN