Pediatric Oral Motor Evaluation Template

A fillable oral motor evaluation for infants and young toddlers with tethered oral tissues, and for older children who cannot yet follow oral motor directions.

Built by Meagan Dungan, M.S., CCC-SLP, this 18-page fillable PDF covers feeding, airway and pre-speech, and records the baby's response to every technique in the Tiny Tongues protocol. Technique numbers 1 to 15 match the protocol.

What's inside

1. Identifying information, referral and concerns
2. A screen to confirm oral motor versus myofunctional therapy
3. Birth, medical and growth history
4. Feeding history for baby and nursing parent, plus solids and cup transitions
5. Breathing, sleep, tension and pre-speech history
6. Provider team input, with sections for the IBCLC (latch, milk supply, transfer, supplementation) and the release provider
7. Infant oral mechanism exam and reflexes
8. Non-nutritive suck assessment, including the floor of the mouth during suck
9. Functional assessment of tethered oral tissues: lingual frenulum, full upper labial frenulum assessment, lower labial and buccal frenula, and infant tool scores
10. Airway and breathing, including the tongue-to-palate sleep check
11. Feeding and pre-speech: breast or bottle observation, spoon with the J-scoop, cup, chewing and early sounds
12. Baseline response to all 15 Tiny Tongues techniques
13. Strength, range of motion and coordination ratings
14. Engagement and regulation
15. Release readiness checklist and phase placement
16. Clinical impressions, diagnosis and coding reminders
17. Goals, with a direct link to the NTX Goal Bank
18. Treatment plan with IBCLC and pediatrician coordination, home routine and discharge criteria
19. Medical necessity, education, consent and signatures

Also included: referral decision guides for physician, GI and dietitian; ENT, airway and sleep; and tethered oral tissue release assessment.

Pairs with

• Tiny Tongues Infant Oral Motor Protocol ($97): therapist-provided oral motor therapy from pre-release to discharge.
• Pediatric Feeding & Myofunctional Goal Bank ($35): measurable goals for latch, suck, oral motor skills and caregiver training.
• Save with the Oral Motor Evaluation + Protocol Bundle ($105) or the Complete Oral Motor Set ($135).

More from NTX

Every NTX resource is built to work with the others. Browse them all on the Therapist Resources page.

Feeding

• Comprehensive Pediatric Feeding Evaluation Template ($15): fillable feeding evaluation, birth to 18, with 5 referral decision guides.
• Gold Standard Pediatric Feeding Evaluation Report Guide ($47): report writing, 3 annotated sample reports, coding, plan of care kit and appeal letters.
• Feeding Evaluation + Report Bundle ($55): the feeding evaluation template and report guide.
• Complete Feeding Documentation Set ($85): feeding evaluation template, report guide and goal bank.

Myofunctional (ages 2 and up)

• Pediatric Myofunctional Evaluation Template ($19): fillable tethered oral tissue evaluation for ages 2 and up: speech, feeding and airway.
• Myofunctional Therapy Protocol for Tethered Oral Tissues (3 Editions) ($97): pre-release to discharge, 14 exercises, in 3 kid-friendly editions.
• Myofunctional Evaluation + Protocol Bundle ($105): the myofunctional evaluation template and the 3-edition protocol.
• Complete Myofunctional Set ($135): myofunctional evaluation template, 3-edition protocol and goal bank.

Instant download after checkout. Single-clinician license; please do not share or redistribute. Resources support, not replace, clinical judgment, your release provider's instructions and payer requirements.