Speech Fluency Evaluation Report Form
Complete this Speech Fluency Evaluation Report Form to document assessment findings and recommendations regarding speech fluency.
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client Name
*
First Name
Last Name
Evaluator Name
*
First Name
Last Name
Stuttering Severity Rating (1 = None, 5 = Severe)
*
None
1
2
3
4
Severe
5
1 is None, 5 is Severe
Frequency and Types of Disfluencies Observed
*
Rows
Never
Rarely
Sometimes
Often
Sound/Syllable Repetitions
1
2
3
4
Prolongations
5
6
7
8
Blocks
9
10
11
12
Interjections
13
14
15
16
Revisions
17
18
19
20
Secondary Behaviors (e.g., facial tension, body movements)
Eye blinking
Facial tension
Body movements
No secondary behaviors observed
Other
Impact on Communication (1 = No impact, 5 = Severe impact)
*
No impact
1
2
3
4
Severe impact
5
1 is No impact, 5 is Severe impact
Situational Variability (check all that apply)
Conversational speech
Reading aloud
Telephone use
Public speaking
Other
Summary and Observations
Recommendations
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