Swallowing Evaluation

[YOUR COMPANY NAME]

Date: March 19, 2050

Patient Information

Patient Name:

Date of Birth:

Gender:

Medical Record Number:

Date of Evaluation:

Primary Diagnosis:

Contact Information:

Introduction

This Swallowing Evaluation Form is designed to assess the swallowing function of stroke survivors. Stroke survivors often encounter swallowing difficulties, which can lead to aspiration and compromise their nutrition and hydration. This evaluation aims to identify any swallowing impairments, determine the risk of aspiration, and guide appropriate interventions to ensure optimal swallowing function and safety.

Background

Stroke survivors frequently experience dysphagia, or swallowing difficulties, due to neurological damage affecting the muscles and nerves involved in swallowing. Dysphagia can lead to serious complications such as aspiration pneumonia, malnutrition, and dehydration if not managed effectively. Therefore, it is crucial to conduct a comprehensive swallowing evaluation to identify swallowing impairments early and implement appropriate rehabilitation strategies to optimize swallowing safety and quality of life for stroke survivors.

Instruction

Please complete all sections of this form thoroughly to ensure a comprehensive assessment of the patient's swallowing function. If you require clarification on any aspect of the evaluation, do not hesitate to consult with the speech-language pathologist conducting the assessment.

Overview

This evaluation form includes various criteria aimed at assessing different aspects of swallowing function in stroke survivors. These criteria encompass medical history, oral motor examination, clinical swallowing assessment, cough reflex testing, fiberoptic endoscopic evaluation of swallowing (FEES), modified barium swallow study (MBSS), functional assessment, and nutritional status assessment.

Purpose of This Form

The primary purpose of this evaluation form is to:

1. Identify swallowing impairments in stroke survivors.

2. Determine the risk of aspiration and other complications related to dysphagia.

3. Guide appropriate interventions and rehabilitation strategies to optimize swallowing function and safety.

4. Ensure adequate nutrition and hydration for stroke survivors to support their overall health and well-being.

Swallowing Evaluation Criteria

Criteria	Description	Evaluation
Medical History	Review of medical history, including presence of stroke, previous swallowing difficulties, and comorbidities that may impact swallowing function.
Oral Motor Examination	Assessment of lip, tongue, jaw, and cheek strength, mobility, and coordination during various oral motor tasks.
Clinical Swallowing Assessment	Observation of swallowing function during trials of various food and liquid consistencies, assessing for signs of aspiration or difficulty swallowing.
Cough Reflex Testing	Evaluation of the strength and efficacy of the cough reflex to protect the airway during swallowing.
Fiberoptic Endoscopic Evaluation of Swallowing (FEES)	Direct visualization of the swallowing process using a flexible endoscope to assess laryngeal and pharyngeal function and identify signs of aspiration.
Modified Barium Swallow Study (MBSS)	Videofluoroscopic assessment of swallowing function, providing detailed information on swallowing physiology and detecting aspiration events.
Functional Assessment	Evaluation of the patient's ability to safely swallow in various real-life situations, such as eating meals and taking medications.
Nutritional Status Assessment	Assessment of nutritional intake, weight changes, and signs of malnutrition or dehydration.

Comment/Feedback

Please provide any additional comments or feedback regarding the swallowing evaluation process or this form. Your input is valuable for improving our services and ensuring the best possible outcomes for our patients.

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