Motricidad Orofacial - Screening

Adaptao de Genaro KF, Berretin-Felix G. Avaliao Miofuncional Orofacial Protocolo MBGR. Rev. CEFAC 2009;
11(2):237-255. Traducido al espaol para fines acadmicos por el Flgo. Felipe Inostroza Allende.

Nombre: __________________________________________________________ N Ficha: ______________

FN: ____/____/____ Edad: ______ aos y ______ meses. Fecha evaluacin: ____/____/____

Motivo e historia de la consulta: _____________________________________________________________

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Informaciones adicionales (salud general, aspectos respiratorios, auditivos/vestibulares, escolares, hbitos

orales, alimentacin, medicamentos, tratamientos): ________________________________________________
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 Aspectos Clnicos Morfo-funcionales
Rostro: Tercio medio: ______ mm Altura: ______ mm Labio inferior: ______ mm
Tercio inferior: ______ mm Ancho: ______ mm Labio superior: ______ mm
Labios: Aspecto: ___________________
Lengua: Aspecto: ___________________ Frenillo: ________________________________________________
Paladar duro: Profundidad: __________________ Velo palatino: ______________________________________
Largura: ______________________ vula: ____________________________________________
Tonsilas palatinas: [ ] adecuada [ ] hipertrofia [ ] no observables
Dientes: Dentadura: ____________________ Salud oral: dientes:________________ enca:_______________
Ausencia de elementos: [ ] no [ ] si: _____________________________________________________
Ausencia de aparato [ ] no [ ] si: _____________________________________________________
Ausencia de prtesis [ ] no [ ] si: _____________________________________________________
Oclusin: TV: ______ mm TH: ______ mm Relacin molar Der: _________ Izq: _________
Observaciones:___________________________________________________________________________________

Posicin habitual: Labios: _______________________________ Lengua: ______________________________

Tonicidad: Labio superior: _______________ Mejilla D: ___________________ Lengua: ____________________
Labio inferior: ________________ Mejilla I: ___________________ Mentn: ____________________
Movilidad: Labios: _______________________________ Lengua: ______________________________
Mandbula: DIMA sin gua lingual: ______ mm Abertura de boca: ______ mm
DIMA con gua lingual: ______ mm Lateralidad Der: ______ mm Izq: ______ mm
Ruido en la ATM: [ ] ausente [ ] presente: _______________________________
Dolor a la [ ] masetero _______ [ ] ATM lateral _______ [ ] esternocleidomastoideo _______
palpacin: [ ] temporal anterior _______ [ ] ATM posterior _______ [ ] trapecio _______
Observaciones:___________________________________________________________________________________

Respiracin: Modo: [ ] nasal Tipo: [ ] medio inferior CPFA: [ ] adecuada

[ ] oronasal [ ] medio superior [ ] alterada
Masticacin: Tipo: [ ] bilateral alternada [ ] unilateral preferencial _____
[ ] bilateral simultnea [ ] unilateral crnica _____
Contracciones musculares atpicas: [ ] ausente [ ] presente _________________________
Tiempo: 1:_____ segundos 2:_____ segundos 3:_____ segundos X:_____ segundos
Deglucin: [ ] adecuada [ ] atpica [ ] adaptada [ ] disfagia
Caractersticas: ________________________________________________
Habla: [ ] sin alteracin [ ] con alteracin ( ) fontica: _______________________________________
( ) fonolgica:_____________________________________
Patrn articulatorio: __________________________________________________________________
Resonancia: _____________________________ Tipo de voz: _____________________________
Observaciones:___________________________________________________________________________________

Conclusin y conducta: ____________________________________________________________________________

Fonoaudilogo(a): ________________________________________________________________________________