Name *

First Name

Last Name

Facility Phone Number *

(###)

###

####

Facility Speech Pathologist Name *

First Name

Last Name

Contact Cell Phone Number *

(###)

###

####

Patient Name *

First Name

Last Name

Patient DOB *

What is the patient's date of birth

MM

DD

YYYY

Ordering Physician Name *

First Name

Last Name

Primary Reason for Consultation *

Check those that apply

Breathing difficulty with PO intake

Breathy vocal sound

Coughing

Choking

Dehydration

Difficulty swallowing

Dizziness

Feeding difficulties

Food/pills getting stuck

GERD/esophageal reflux

Globus sensation

Heartburn

Hoarse vocal quality

Malnutrition

Moist cough

Pneumonia

Pocketing

Poor PO intake

Recurrent pneumonia

Respiratory distress

Shortness of breath

Spitting food/saliva

Suspect silent aspiration

Tearing with oral intake

Vomiting

Weight loss

Wet vocal quality

Wheezing with PO

Other Reasons for Swallowing Evaluation

Determine least restrictive diet

Determine safest diet

Improvement with swallowing

Decline with swallowing

Feeding evaluation

Pre-tx evaluation of swallow

Suspect reflux

If Patient does not have a PEG, will the patient be in favor of pursuing PEG if recommended?

Yes

No

Unsure

Dysphagia Symptoms first Noted: *

MM

DD

YYYY

Frequency of Symptoms *

With all PO

With liquids

With solids

Pertinent Medical History/Diagnosis *

CVA

Parkinson's

GERD

Alzheimer's

Dementia

CHF

COPD

Pneumonia

None of the above

What tx is being used? *

Oral/paryngeal exercises

Estim

Thermal stim

None yet - Awaiting physiologic evaluation

Other

Dentition: *

Natural

Partials

Dentures

Endentulous

Current Diet: *

Regular

Mech soft

Pureed

NPO

Liquids: *

Regular/thin

Nectar

Honey

Pudding

NPO

Mobile/onsite visit requested by Doctor due to: *

Emergent request due to elevated aspiration risk

Transport negatively impacts underlying physical condition

Fatigues easily, compromising test participation

Transport exacerbates behavioral problems