Nome Completo:____________________________________________________________

Data de Nascimento:_________________ Idade: _________

Sexo:____________________________

Encaminhado por:

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Queixas (sintomas, duração, história pregressa de queixa)

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Avaliação Oromiofacial (lábios: sensibilidade, postura, mobilidade, tônus)

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Avaliação da Disfagia

Dificuldade para se alimentar: ⃝ SIM ⃝ NÃO

Via Oral: ⃝ SIM ⃝ NÃO

Sonda Nasoenteral: ⃝ SIM ⃝ NÃO

Observações:

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Qualidade Vocal
⃝ Adequada ⃝ Aspirado Ataque Vocal
⃝ Alta ⃝ Tensa ⃝ Adequado
⃝ Aspirado ⃝ Trêmula ⃝ Aspirado
⃝ Compensação Nasal ⃝ Brusco
⃝ Gudizado
Ritmo
⃝ Gutural Observações
⃝ Adequado à intenção
⃝ Inadequada do discurso _____________________
⃝ Monótona ⃝ Inadequado à intenção _____________________
do discurso _____________________
⃝ Pastosa _____________________
⃝ Rouca _____________________
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⃝ Soprosa _____________________
Avaliação de Linguagem (Aspectos linguísticos – sintaxe, semântica,
pragmática, fonética, fonologia)

Linguagem Oral

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Linguagem Escrita

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Internações, Medicamentos em uso

Exames Realizados

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Hipótese Diagnóstica

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Conduta

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