Swallowing Assessment Form – Fill Out and Use This PDF

Clinical Swallowing Evaluation Template 1

Clinical Swallowing Exam

Name:

ID/Medical record number:

Date of exam:

Referred by:

Reason for referral:

Medical diagnosis:

Date of onset of diagnosis:

Other relevant medical history/diagnoses/surgery

Medications:

Allergies:

Pain:

Primary languages spoken:

Educational history:

Occupation:

Hearing status:

Vision status:

Tracheostomy:

Mechanical ventilation:

Subjective/Patient Report:

Symptoms reported by patient (check all that apply): __Drooling

__Coughing __Choking __Difficulty swallowing:

__Solids __Liquids __Pills

__Pain on swallowing __Food gets stuck __Weight loss

__History of aspiration or pneumonia ______________________

__Other: _____________________________________________

Current diet (check all that apply)

Solids: __regular; __mechanical, __mechanical soft, __chopped, __minced, __pureed; other: ______________

Liquids: __thin; __nectar thick; __honey thick; __pudding thick; other: ____________

NPO: Alternative nutrition method __Nasogastric tube

Templates are consensus-based and provided as a resource for members of the American Speech- Language-Hearing Association (ASHA). Information included in these templates does not represent official ASHA policy.

Clinical Swallowing Evaluation Template 2

__Gastrostomy __Jejunostomy

__Total parenteral nutrition (TPN)

Feeding Method: __Independent in self-feeding __Needs some assistance __Dependent for feeding

Endurance during meals: __Good __Fair __Poor __Variable

Observations/Informal Assessment:

Mental Status (check all that apply): __ alert

__ responsive __ cooperative __ confused __ lethargic __ impulsive __ uncooperative __ combative __ unresponsive

Objective Assessment:

Oral Status

Dentition

__WNL

__Missing teeth ________________

__Decay

__Dentures present __upper __lower

Templates are consensus-based and provided as a resource for members of the American Speech- Language-Hearing Association (ASHA). Information included in these templates does not represent official ASHA policy.

Clinical Swallowing Evaluation Template 3

Oral Motor, Respiration, and Phonation

Lips

WNL, mild, mod, severe impairment

Observation at rest (WNL, Edema, Erythema, Lesion): __________________

Symmetry, range, speed, strength, tone:

Pucker ______________________________________

Retraction ______________________________________

Alternating pucker/retraction _________________________________

Involuntary movement (e.g., chorea, dystonia, fasciculations, myoclonus, spasms, tremor): __________________________________________________

Tongue

WNL, mild, mod, severe impairment

Observation at rest (WNL, Edema, Erythema, Lesion):

Symmetry, range, speed, strength, tone:

Protrusion _______________________

Retraction _______________________

Lateralization ________________________

Involuntary movement: _______________________

Jaw

WNL, mild, mod, severe impairment

Observation at rest: ____________________

Symmetry, range, strength, tone:

Opening _______________________

Closing ________________________

Lateralization ___________________

Protrusion ______________________

Retraction ______________________

Involuntary movement: _________________

Soft palate

WNL, mild, mod, severe impairment

Observation at rest (WNL, Edema, Erythema, Lesion): ___________________

Symmetry, range, strength, tone: ____________________________________

Elevation _______________________________________________________

Sustained elevation _______________________________________________

Alternating elevation/relaxation _____________________________________

Involuntary movement:

Comments:

Templates are consensus-based and provided as a resource for members of the American Speech- Language-Hearing Association (ASHA). Information included in these templates does not represent official ASHA policy.

				Clinical Swallowing Evaluation Template 4
Voice quality
Activity		Duration	Quality		Loudness
Phonation		WNL	WNL		WNL
		Mildly impaired	Breathy		Reduced
		Moderately impaired	Hoarse		Excessive
		Severely impaired	Harsh
			Strained/strangled

Respiratory Sufficiency and Coordination:

__WNL

__Mildly impaired

__Moderately impaired __Severely impaired

Comments: ________________________________

Food and Liquid Trials

Position during assessment: (check all that apply) __Upright

__Slightly reclined __Fully reclined

Comments: ________________________________

Factors affecting performance:

__No difficulties participating in study

__Impairment or difficulty noted in mental status

__Impairment or difficulty noted in following directions __Impairment or difficulty noted in endurance __Other: __________________________________

Saliva Swallows:

__WNL __Impaired __Xerostomia

Observations: ________________________________

Templates are consensus-based and provided as a resource for members of the American Speech- Language-Hearing Association (ASHA). Information included in these templates does not represent official ASHA policy.

Clinical Swallowing Evaluation Template 5

Liquid Trials

Thin Liquids	Nectar-thick	Honey-thick	Pudding-thick
Administered	Administered by	Administered by	Administered by
by (Check all	(Check all that	(Check all that	(Check all that apply)
that apply)	apply)	apply)	Cup
Cup	Cup	Cup	Spoon
Spoon	Spoon	Spoon	Straw
Straw	Straw	Straw	Self-fed
Self-feeding	Self-fed	Self-fed	Fed by examiner
Feeding by	Fed by examiner	Fed by examiner
examiner
Amounts:	Amounts:	Amounts:	Amounts:
Response:	Response:	Response:	Response:
Volitional cough:	Volitional cough:	Volitional cough:	Volitional cough:
yes/no	yes/no	yes/no	yes/no
Volitional throat	Volitional throat	Volitional throat	Volitional throat clear:
clear: yes/no	clear: yes/no	clear: yes/no	yes/no
Spontaneous	Spontaneous	Spontaneous	Spontaneous cough
cough during	cough during	cough during	during trials: yes/no
trials: yes/no	trials: yes/no	trials: yes/no	Spontaneous throat
Spontaneous	Spontaneous throat	Spontaneous throat	clear during trials:
throat clear	clear during	clear during	yes/no
during trials:	trials: yes/no	trials: yes/no
yes/no
Strategies	Strategies	Strategies	Strategies Attempted
Attempted and	Attempted and	Attempted and	and Response:
Response:	Response:	Response:
Swallowing	Swallowing	Swallowing	Swallowing Duration
Duration	Duration	Duration	___ sec.
(introduction of	___ sec.	___ sec.
bolus to
completion of
pharyngeal
stage): ___sec.

Comments __________________________________________________

Templates are consensus-based and provided as a resource for members of the American Speech- Language-Hearing Association (ASHA). Information included in these templates does not represent official ASHA policy.

Clinical Swallowing Evaluation Template 6

Solid Food Trials

Food Item:	Food Item:	Food Item:	Food Item:
Administered	Spoon/fork	Spoon/fork	Spoon/fork
by:	Self-fed	Self-fed	Self-fed
Spoon/fork	Fed by examiner	Fed by examiner	Fed by examiner
Self-fed
Fed by examiner
Amounts:	Amounts:	Amounts:	Amounts:
Response:	Response:	Response:	Response:
(circle all that		(check all that	(check all that apply)
apply)		apply)	Volitional cough:
Volitional cough:	Volitional cough:	Volitional cough:	yes/no
yes/no	yes/no	yes/no	Volitional throat clear:
Volitional throat	Volitional throat	Volitional throat	yes/no
clear: yes/no	clear: yes/no	clear: yes/no	Spontaneous cough
Spontaneous	Spontaneous	Spontaneous	during trials: yes/no
cough during	cough during	cough during	Spontaneous throat
trials: yes/no	trials: yes/no	trials: yes/no	clear during trials:
Spontaneous	Spontaneous throat	Spontaneous throat	yes/no
throat clear	clear during	clear during
during trials:	trials: yes/no	trials: yes/no
yes/no
Strategies	Strategies	Strategies	Strategies Attempted
Attempted and	Attempted and	Attempted and	and Response:
Response:	Response:	Response:
Swallowing	Swallowing	Swallowing	Swallowing Duration
Duration	Duration	Duration	___ sec.
(introduction of	___ sec.	___ sec.
bolus to
completion of
pharyngeal
stage): ___sec.

Observations: (laryngeal elevation, other)

________________________________________________________________________

________________________________________________________________________

Templates are consensus-based and provided as a resource for members of the American Speech- Language-Hearing Association (ASHA). Information included in these templates does not represent official ASHA policy.

Clinical Swallowing Evaluation Template 7

Findings

__Swallowing within normal limits __Swallowing diagnosis:

__dysphagia unspecified __oral phase dysphagia __oropharyngeal phase dysphagia __pharyngeal phase dysphagia

__pharyngoesophageal phase dysphagia __other dysphagia

__Severity: __mild

__mild-moderate __moderate __moderate-severe __severe

Characterized by: ______________________________________________________

Contributing Factors to Swallowing Impairment __Reduced alertness or attention __Difficulty following directions __Reduced oral strength/coordination/sensation __Mastication inefficiency

__Impaired oral-pharyngeal transport

__Impaired velopharyngeal closure/coordination __Delayed swallow initiation

__Reduced laryngeal excursion

__Other ___________________________________

Prognosis: __Good __Fair __ Poor, based on ________________________

Impact on Safety and Functioning (check all that apply) __No limitations

__Risk for aspiration: ______________________________

__Risk for inadequate nutrition/hydration: ______________________________

NOMS Swallowing Score (1-7) ____

Templates are consensus-based and provided as a resource for members of the American Speech- Language-Hearing Association (ASHA). Information included in these templates does not represent official ASHA policy.

Clinical Swallowing Evaluation Template 8

Recommendations:

Instrumental assessment: __yes __no

__Videofluoroscopic Swallowing Study __Endoscopic Swallowing Study

Swallowing treatment: __yes __no

Frequency: Duration:

Diet Texture Recommendations:

Solids: __regular; __mechanical, __mechanical soft, __chopped, __minced, __pureed; other: ______________

Liquids: __thin; __nectar thick; __honey thick; __pudding thick; other: ____________

NPO with alternative nutrition method: ____________________________

Alternative nutrition method with pleasure feedings: _________________

Other: _______________________________________

Safety precautions/swallowing recommendations (check all that apply): __Supervision needed for all meals

__1 to 1 close supervision __1 to 1 distant supervision

__To be fed only by trained staff/family __To be fed only by SLP

__Feed only when alert __Reduce distractions

__Needs verbal cues to use recommended strategies __Upright position at least 30 minutes after meals __Small sips and bites when eating

__Slow rate; swallow between bites __No straw

__Sips by straw only

__Multiple swallows: ____________________

__Alternate liquids and solids

__Sensory enhancement (flavor, texture, temperature): ______________

__Other _________________________

Other recommended referrals: __Dietetics __Gastroenterology __Neurology __Otolaryngology __Pulmonology

__Other _________________________

Templates are consensus-based and provided as a resource for members of the American Speech- Language-Hearing Association (ASHA). Information included in these templates does not represent official ASHA policy.

Clinical Swallowing Evaluation Template 9

Patient/Caregiver Education __Described results of evaluation

__Patient expressed understanding of evaluation and agreement with goals and treatment plan

__Family/caregivers expressed understanding of evaluation and agreement with goals and treatment plan.

__ Patient expressed understanding of safety precautions/feeding recommendations

__ Family/caregivers expressed understanding of safety precautions/feeding recommendations

__Patient expressed understanding of evaluation but refused treatment __ Patient requires further education

__Family/caregivers require further education

Treatment Plan

Long Term Goals

Short Term Goals

Templates are consensus-based and provided as a resource for members of the American Speech- Language-Hearing Association (ASHA). Information included in these templates does not represent official ASHA policy.