SCREENING ASSESSMENT

Name: Address: Assessor: QUALITY PITCH PITCH RANGE LOUDNESS NASAL RESONANCE ORAL RESONANCE RATE PROSODY AERODYNAMICS RELATED OBSERVATIONS CLIENT PERCEPTION breathy hoarse husky whispered too high too low restricted too loud too quiet hypernasal hyponasal throaty fast slow inadequate variability excessive variability S/Z ratio MPT glottal fry diplophonia phonation breaks fluctuations in quality [self-rating scale] 0 present present present present 1 normal 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 dob: Screening date: mild 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 (seconds) not present not present not present not present 2 3 mod 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 sev 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

(Severity: 1 = mild deviation 3 = moderate deviation 5 = severe deviation)

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CVE2 2003 Graham Williamson www.speech-therapy-information-and-resources.com