Motor Speech Evaluation Template 1
Templates are consensus-based and provided as a resource for members of the American Speech-
Language-Hearing Association (ASHA). Information included in these templates does not represent official
ASHA policy.
Motor Speech Disorders Evaluation
Name:
ID/Medical record number:
Date of exam:
Referred by:
Reason for referral:
Medical diagnosis:
Date of onset of diagnosis:
Other relevant medical history/diagnoses/surgery
Medications:
Allergies:
Pain:
Primary languages spoken:
Educational history:
Occupation:
Hearing status:
Vision status:
Tracheostomy:
Mechanical ventilation:
Subjective/Patient Report:
Observations/Informal Assessment:
Mental Status (check all that apply):
__ alert
__ responsive
__ cooperative
__ confused
__ lethargic
__ impulsive
__ uncooperative
__ combative
__ unresponsive
Motor Speech Evaluation Template 2
Templates are consensus-based and provided as a resource for members of the American Speech-
Language-Hearing Association (ASHA). Information included in these templates does not represent official
ASHA policy.
Oral Motor, Respiration, and Phonation
Lips
WNL, mild, mod, severe impairment
Observation at rest (WNL, Edema, Erythema, Lesion): __________________
Symmetry, range, speed, strength, tone:
Pucker ______________________________________
Retraction ______________________________________
Alternating pucker/retraction _________________________________
Involuntary movement (e.g., chorea, dystonia, fasciculations, myoclonus, spasms,
tremor): __________________________________________________
Tongue
WNL, mild, mod, severe impairment
Observation at rest (WNL, Edema, Erythema, Lesion):
Symmetry, range, speed, strength, tone:
Protrusion _______________________
Retraction _______________________
Lateralization ________________________
Involuntary movement: _______________________
Jaw
WNL, mild, mod, severe impairment
Observation at rest: ____________________
Symmetry, range, strength, tone:
Opening _______________________
Closing ________________________
Lateralization ___________________
Protrusion ______________________
Retraction ______________________
Involuntary movement: _________________
Soft palate
WNL, mild, mod, severe impairment
Observation at rest (WNL, Edema, Erythema, Lesion): ___________________
Symmetry, range, strength, tone: ____________________________________
Elevation _______________________________________________________
Sustained elevation _______________________________________________
Alternating elevation/relaxation _____________________________________
Involuntary movement:
Motor Speech Evaluation Template 3
Templates are consensus-based and provided as a resource for members of the American Speech-
Language-Hearing Association (ASHA). Information included in these templates does not represent official
ASHA policy.
Respiration/Phonation
Observations/formal measures administered: _______________________________
Activity
Stimulus
Quality
Duration
Loudness
Steadiness
Phonation
WNL
Breathy
Hoarse
Harsh
Strained-
strangled
___ secs
WNL
Mildly impaired
Moderately
impaired
Severely impaired
WNL
Monoloudness
Excessive loudness
Variable loudness
Oral reading
WNL
Breathy
Hoarse
Harsh
Strained-
strangled
WNL
Mildly impaired
Moderately
impaired
Severely impaired
WNL
Monoloudness
Excessive loudness
Variable loudness
Conversation
WNL
Breathy
Hoarse
Harsh
Strained-
strangled
WNL
Mildly impaired
Moderately
impaired
Severely impaired
WNL
Monoloudness
Excessive loudness
Variable loudness
Oral Agility: Diadochokinetic Rates
Quality
Comments
P^
WNL/mild/mod/sev
T^
WNL/mild/mod/sev
K^
WNL/mild/mod/sev
P^T^K^
WNL/mild/mod/sev
Other oral agility: ________________________________________________
Speech Intelligibility
Standardized dysarthria/apraxia tests: ___________________________
Non-Standardized Tasks: _____________________________________
Stimulus
Comments
Phoneme
Word
Sentence
Conversation
Motor Speech Evaluation Template 4
Templates are consensus-based and provided as a resource for members of the American Speech-
Language-Hearing Association (ASHA). Information included in these templates does not represent official
ASHA policy.
Awareness/strategy use
__Limited to no awareness of motor speech impairment
__Aware of motor speech impairment; unable to use strategies to improve
intelligibility
__Uses strategies intermittently to improve intelligibility or listener’s
understanding of message
__Uses strategies effectively and consistently to improve intelligibility or
listener’s understanding of message
Findings
__Motor speech within normal limits
__ (mild, mild-moderate, moderate, moderate-severe, severe) apraxia
characterized by _______________________________________
__ (mild, mild-moderate, moderate, moderate-severe, severe) dysarthria
characterized by ___________________________________________
Dysarthria type:
__ataxic
__hypokinetic
__hyperkinetic
__spastic
__flaccid
__mixed
__unilateral upper motor neuron
Impact of Motor Speech Impairment on Functioning:
Activity Limitations and Participation Restrictions (check all that apply):
Mild Moderate Severe
General tasks and demands ______ ________ ______
Household tasks ______ ________ ______
Interpersonal interactions ______ ________ ______
Education ______ ________ ______
Employment ______ ________ ______
Community ______ ________ ______
Other_____________ ______ ________ ______
Safety Risks Mild Moderate Severe
Motor Speech Evaluation Template 5
Templates are consensus-based and provided as a resource for members of the American Speech-
Language-Hearing Association (ASHA). Information included in these templates does not represent official
ASHA policy.
Being left alone at home ______ ________ ______
Traveling alone in community ______ ________ ______
Other ___________________ ______ ________ ______
Prognosis:
__Good
__Fair
__Poor
Based on ________________________
Recommendations: (check all that apply)
__ Speech-language pathology treatment
Frequency: Duration:
__ Augmentative-Alternative Communication or Speech Generating Device
evaluation
__Other suggested referrals:
__Neurology
__Otolaryngology
__Pulmonology
__Other
Patient/Family Education
__Described results of evaluation
__Patient expressed understanding of evaluation and agreement with goals
and treatment plan
__Patient expressed understanding of evaluation but refused treatment
__Family/caregivers expressed understanding of evaluation and agreement
with goals and treatment plan.
__Patient demonstrated recommended strategies
__Family/caregivers demonstrated recommended strategies
__Patient requires further education on strategies
__Family/caregivers require further education on strategies
__Other ______________________________
Treatment Plan
Long Term Goals
Short Term Goals