PROGRAMA DE INTEGRACIN ESCOLAR

LICEO HC JORGE TEILLIER S.

EVALUACIN DE LA TARTAMUDEZ

I. ANTECEDENTES PERSONALES

Nombre : ____________________________________________________
Fecha de Nacimiento : ____________________________________________________
Edad : ____________________________________________________
Escolaridad : ____________________________________________________
Fecha de Evaluacin : ____________________________________________________
Examinador : ____________________________________________________

II. MOTIVO DE CONSULTA

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III. ANTECEDENTES DEL PROBLEMA

a) Comienzo:
Cundo: ___________________________________________________
Espontneo: ________________________________________________
Provocado: _________________________________________________

b) Evolucin: _______________________________________________________
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c) Tratamiento anterior: _______________________________________________

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d) Caractersticas de la personalidad: ____________________________________

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e) Conciencia de la alteracin: __________________________________________

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f) Fenmenos emocionales: ____________________________________________

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g) Factor hereditario: _________________________________________________

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 PROGRAMA DE INTEGRACIN ESCOLAR
LICEO HC JORGE TEILLIER S.

h) Relacin Familiar: _________________________________________________

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IV. ANTECEDENTES DE EVALUACIN:

Evaluacin de O.F.A.:

Labios: _______________________ Lengua:

____________________________
Dientes: ______________________ Paladar duro: ________________________
Paladar blando: ________________ Mordida: ___________________________
Frenillo: ______________________ Maxilar: ____________________________

Praxias Bucolingofaciales: ________________________________________

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Caractersticas de la Respiracin:

a) Tipo Respiratorio:
Costodiafragmtico: _________
Mixto: _________
Costal Superior: _________

b) Modo Respiratorio:
Bucal: ________
Nasal: ________
Mixto: ________

c) Coordinacin Fonorespiratoria:
Adecuada: ________
Inadecuada: ________

Caractersticas de la musculatura:
a) En Reposo:

-Facial: _______________________________________________
-Cuello: _______________________________________________
-Hombros: _____________________________________________
 PROGRAMA DE INTEGRACIN ESCOLAR
LICEO HC JORGE TEILLIER S.

b) En Fonacin:

-Facial: _______________________________________________
-Cuello: _______________________________________________
-Hombros: _____________________________________________

Parmetros del Habla:

Fluidez:_______________________________________________________________
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Ritmo:________________________________________________________________
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Prosodia:______________________________________________________________
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Habla espontnea:
Conducta verbal:
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Conducta Motora Asociada:
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Caractersticas de los enunciados:
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Fenmenos Emocionales asociados:
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Lectura sin ritmo:
Conducta verbal:
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Conducta Motora Asociada:
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Caractersticas de los enunciados:
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Fenmenos Emocionales asociados:
_________________________________________________________________________
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Lectura con ritmo:
Conducta verbal:
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 PROGRAMA DE INTEGRACIN ESCOLAR
LICEO HC JORGE TEILLIER S.

Conducta Motora Asociada:

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Caractersticas de los enunciados:
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Fenmenos Emocionales asociados:
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Repeticin de palabras y oraciones:

Conducta verbal:
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Conducta Motora Asociada:
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Caractersticas de los enunciados:
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Fenmenos Emocionales asociados:
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Series automticas:

Conducta verbal:
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Conducta Motora Asociada:
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Caractersticas de los enunciados:
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Fenmenos Emocionales asociados:
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HIPTESIS DIAGNSTICA:

a) Tipo de Tartamudez:
 PROGRAMA DE INTEGRACIN ESCOLAR
LICEO HC JORGE TEILLIER S.

- Tnica: ____________
- Clnica:____________
- Mixta:_____________

b) Gravedad:
- Ligera:______________
- Moderada:___________
- Grave:_______________
- Muy grave:___________

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Constanza Rivas Ibarra
Fonoaudiloga
N de registro: 67.966