□ □ □ □ Occlusion Class I Class II Class III Anterior open bite Dentition □ □ □ □ Unremarkable Supernumerary Missing teeth Malaligned Tongue □ □ □ □ Unremarkable Poor mobility Abnormal posture Tongue tie □ □ Palatal Fistula Present Absent □ □ □ Fistula Size Minute < than 2 mm between 2-5 mm Medium □ □ between 5-8 mm Large >8 mm Complete breakdown □ □ □ Fistula Location Uvula Soft palate Junction soft/hard palate □ □ □ □ Hard palate-post alveolus Buccal sulcus Other (describe) Hard palate and buccal sulcus Palate Mobility □ □ □ □ Marked Moderate Slight None S.P. □ □ □ □ Bifid uvula Notch Blue/thin looking Suspected incorrect □ alignment Apparently short □ Tonsils □ Apparently deep pharynx □ Pharyngeal wall movement □ Pharyngeal flap □Apparently □ □ Language normal Delayed Disordered Identifiable aetiology □ □ □ □Malocclusion Suspected VPI Confirmed VPI Abnormal dentition □ □ □ □ Diagnosed hearing loss Suspected hearing loss Oral fistula □ □ □ palate history Intellectual deficit Developmental Environmental □ Syndrome Areas requiring further assessment
Occlusion □ Class I □ Class II □ Class III □ Anterior open bite Dentition □ Unremarkable □ Supernumerary □ Missing teeth □ Malaligned Tongue □ Unremarkable □ Poor mobility □ Abnormal posture □ Tongue tie Palatal Fistula □ Present □ Absent Fistula Size □ Minute < than 2 mm □ between 2-5 mm □ Medium between 5-8 mm □ Large >8 mm □ Complete breakdown Fistula Location □ Uvula □ Soft palate □ Junction soft/hard palate □ Hard palate-post alveolus □ Buccal sulcus □ Other (describe) □ Hard palate and buccal sulcus Palate Mobility □ Marked □ Moderate □ Slight □ None S.P. □ Bifid uvula □ Notch □ Blue/thin looking □ Suspected incorrect alignment □ Apparently short □ Tonsils □ Apparently deep pharynx □ Pharyngeal wall movement □ Pharyngeal flap Language □Apparently normal □ Delayed □ Disordered Identifiable aetiology □ Suspected VPI □ Confirmed VPI □ Abnormal dentition □Malocclusion □ Diagnosed hearing loss □ Suspected hearing loss □ Oral fistula □ palate history □ Intellectual deficit □ Developmental □ Environmental □ Syndrome Areas requiring further assessment
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