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: