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Nr.fisei___________
Data intocmirii__________________
Numele examinatorului_______________________________
I. DATE GENERALE
1.1.Personale
Numele de familie____________________prenumele_____________________nascut in
anul________luna________ziua______.Domiciliul______________________________
__________________________.Institutia______________________________________
1.2.Familiale
Numele Nationa- Varsta Studii Ocupatia Locul de munca
Parintilor litate
TATA:
_________ __________ _______ _______ ___________ ____________
MAMA:
_________ __________ _______ _______ ___________ ____________
1.3.Motivul examinarii
Trimis de_____________________________________________________________
Cu ce acuze este trimis__________________________________________________
II.ANAMNEZA
2.1.Familiala
Structura familiei______________________________________________________
Al catelea copil este_________Starea de sanatate a membrilor familiei____________
_______________________________________________________________________
Persoane cu tulburari de limbaj in familie___________________________________
Relatiile in familie:a.intre parinti__________________________________________ b.fata de copil______________________c.atitudinea fata de defectul de vorbire
al co pilului_______________________________________________________________
Daca sunt stangaci sau ambidextri in familie_________________________________
Conditiile materiale,igienice,educative ale familiei____________________________
_____________________________________________________________________
2.2.Personala
Sarcina_______________________________________________________________
Nasterea:la termen_______;la ___luni;greutatea____________inaltimea__________.
Alimentatia suptul 4 6 8 10 12 mananca independent 16 18 20 22 24
Motricitatea sade 6 7 8 9 10
Merge 10 12 14 16 18
Aparitia dintilor 5 6 7 8 9
Deprinderi igi- controlul de enico-sanitare fecatiei 4 6 8 10 12 controlul mic tiunii diurne 8 10 12 14 16 conrtolul mic tiunii nocturne14 16 18 20 22
Antecedente fiziologice si patologice_______________________________________
________________________________________________________________________
Tulburari psihice_______________________________________________________
2.3.Date asupra auzului si limbajului
Ganguritul_______________________________________________________________
Evolutia vorbirii lalatiunea 4 6 8 10 12 primul cuvant 8 10 12 14 16 prima propo zitiune 14 16 18 20 22
Ritmul vorbirii___________________________________________________________
Limba materna si cea a mediului inconjurator___________________________________
________________________________________________________________________
Intelegerea vorbirii persoanelor din jur_________________________________________
________________________________________________________________________
Insusirea unei limbi straine__________________________________________________
Insusirea scierii si a citirii___________________________________________________
Cand a aparut tulburarea de limbaj____________________________________________
Cauza reala sau presupusa__________________________________________________
Daca a beneficiat de tratament logopedic_______________________________________
________________________________________________________________________
III. EXAMENUL SOMATIC SI FUNCTIONAL
3.1. Aspectul somatic
Conformatia capului_______________________________________________________
Cavitatea toracica_________________________________________________________
Membrele_______________________________________________________________
MECANISMELE periferice ale vorbirii_______________________________________
Cavitate bucala_____________________valul palatin____________________________
Limba_____________buzele________________________________maxilarele________
__________________Dantura_______________________________________________
3.2. Motricitatea
Mersul__________________________________________________________________
Coordonarea generala a miscarilor____________________________________________
Lateralitate______________________________________________________________
Motricitatea mimico-faciala_________________________________________________
Motricitatea limbii________________________________________________________
Motricitatea buzelor_______________________________________________________
Motricitatea valului palatin__________________________________________________
Ritmul acustico-motor_____________________________________________________
3.3. Respiratia
Diferentierea dintre respiratia orala si nazala____________________________________
________________________________________________________________________
Durata expiratiei si pauzele expiratorii_________________________________________
________________________________________________________________________
Tipul de respiratie_________________________________________________________
3.4. Functia auditiva
Acuitatea auditiva_________________________________________________________
Atentia auditiva___________________________________________________________
Memoria auditiva_________________________________________________________
Capacitatea de diferentiere fonematica________________________________________
Capacitatea de analiza si sinteza fonematica____________________________________
Auzul fonematic__________________________________________________________
Auzul muzical____________________________________________________________
3.5. Functia fonatorie
Intensitatea vocii__________________________________________________________
Calitatea vocii____________________________________________________________
Mutatia vocii_____________________________________________________________
IV. LIMBAJUL ORAL SI SCRIS
4.1. Pronuntia sunetelor si a cuvintelor
Reproducerea fonemelor pe baza de auz_______________________________________
Reproducerea fonemelor dupa modelul logopedului______________________________
Reproducerea fonemelor pe baza de citire______________________________________
Miscari articulatorii defectuoase______________________________________________
Omisiuni de sunete________________________________________________________
Confundarea sunetelor_____________________________________________________
Estomparea terminatiei cuvintelor____________________________________________
Capacitatea fonematica_____________________________________________________
4.2. Ritmul si fluenta vorbirii
Ritmul vorbirii___________________________________________________________
Poticniri : la sunete_________silabe_________cuvinte___________________________
Repetari: de sunete_________silabe________cuvinte____________________________
Spasme articulatorii (si muschii afectati)_______________________________________
Calitatea vorbirii : independenta_______________reflectata_______________in
soapta________structuri verbale memorate____________________________________
Calitatea citirii : independenta__________________reflectata_____________________
Asociata _____________________________________________________________
Fluenta vorbirii________________________________________________________
Diverse fobii__________________________________________________________
Miscari concomitente___________________________________________________
Vorbirea in diferite situatii_______________________________________________
Balbaiala in cant (si la instrumernte)_______________________________________
Balbaiala in scris_______________________________________________________
4.3. Scrierea si citirea
Copiere______________________________________________________________
Dictare______________________________________________________________
Compunere___________________________________________________________
Structura grafica_______________________________________________________
Structura logica________________________________________________________
Limbajul scris_________________________________________________________
Citirea_______________________________________________________________
V. DIAGNOSTICUL TULBURARILOR DE LIMBAJ
5.1. Caracterizarea limbajului si a persoanei examinate.
Vorbirea ______________________________________________________________
Scrisul________________________________________________________________
Cititul_________________________________________________________________
Succesul scolar__________________________________________________________
Conduita_______________________________________________________________
5.2. Cauzele si diagnosticul
Cauze presupuse__________________________________________________________
Cauze confirmate_________________________________________________________
Diagnosticul initial________________________________________________________
Evolutia diagnosticului_____________________________________________________
Diagnosticul final_________________________________________________________
