Nr. fisei_______________ Numele examinatorului________ b6z10zx
Datele examinatorului____________

I. DATE GENERALE

1.1 Personale
Numele de familie_________________prenumele_______________________________ nascut in anul__________luna_______ziua_____domiciliul_______________________ institutia________________________________________________________________
1.2. Familiale numele parintilor nationalitatea varsta studii ocupatia locul de munca 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 pronuntie al copilului_____________________________
Daca sunt stangaci sau ambidextri in familie____________________________________
Conditiile materiale, igenice, educative ale familiei_______________________________
2.2. Personala
Sarcina__________________________________________________________________
Nasterea : la termen_____________la _____luni;greutatea_________________________
Tulburari psihice__________________________________________________________
2.3.Date asupra auzului si limbajului
Ganguritul_______________________________________________________________
Evolutia vorbirii lalatiunea 4 6 8 10 1 pimul cuvant 8 10 12 14 1 prima propozitie 14 16 18 20 2
Ritmul vorbirii___________________________________________________________
Limba materna si cea a mediului inconjurator___________________________________
________________________________________________________________________
Intelegera vorbirii persoanelor din jur_________________________________________
________________________________________________________________________
Insusirea unei limbi straine__________________________________________________
Insusirea scrierii 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_______________________________________________________
________________________________________________________________________________________________________________________________________________
Mecanisme periferice ale vorbirii_____________________________________________
Cavitatea bucala_________________valul palatin_______________________________
______________________limba_____________________________________________ buzele_________________maxilarele_________________________________________ dantura__________________________________________________________________
3.2.Motricitatea
Mersul__________________________________________________________________
Coordonarea generala a miscarilor____________________________________________
Lateralitatea______________________________________________________________
Motricitatea limbii________________________________________________________
Motricitatea mimico-faciala_________________________________________________
Motricitatea buzelor_______________________________________________________
Motricitatea valului palatin_________________________________________________
Ritmul acustico-motor_____________________________________________________
3.3.Respiratia
Diferentierea dintre respiratia orala si cea nazala_________________________________
Tipul de respiratie_________________________________________________________
3.4.Functia auditiva
Atentia auditiva___________________________________________________________
Memoria auditiva_________________________________________________________
Capacitatea de diferentiere fonematica_________________________________________
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 pe baza de citire______________________________________
Miscari articulatorii defectuoase______________________________________________
Miscari asociate__________________________________________________________
Omisiuni de sunete________________________________________________________
Confundarea sunetelor_____________________________________________________
Estomparea terminatiei cuvintelor____________________________________________
4.2.Ritmul si fluenta vorbirii
Fluenta__________________________________________________________________
Ritmul vorbirii___________________________________________________________
Poticniri la sunete_______________________silabe_____________________________
_____cuvinte_____________________________________________________________
Repetari de sunete______________________silabe______________________________
_____cuvinte_____________________________________________________________
Spasme articulatorii si muschii afectati________________________________________
Calitateavorbirii:independenta_______________________________________________ reflectata________________________________________________________________
Calitatea citirii:independente:________________________________________________ reflectata_____________________________________________________________
Diverse fobii_____________________________________________________________
Miscari concomitente______________________________________________________
Vorbirea in diferite situatii__________________________________________________
Balbaiala in cant si la instrumente____________________________________________
Balbaiala in scris__________________________________________________________
4.3.Scrierea si citirea
Copiere_________________________________________________________________
Dictare__________________________________________________________________
Compunere______________________________________________________________
Structura grafica__________________________________________________________
Structura logica___________________________________________________________
Citire___________________________________________________________________

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_________________________________________________________

IV. Evidenta frecventei la lectiile logopedice
LUNA ZIUA
Octombrie
Noiembrie
Decembrie
Ianuarie
Februarie
Martie
Aprilie
Mai

IV.Observatii asaupra desfasurarii procesului de corectare-metodele,procedeele,exercitiile folosite in diferite faze ale corectarii,rezultatele partiale,materialul intuitiv,auxiliar folosit,impediomentele corectarii,ajutorul primit din partea parintilor,medicilor de specialitate,cadrelor didactice:recidive sau greutati survenite in timpul tratamentului logopedic.