Department of Mental Retardation

Department of Developmental Services

Swallowing Evaluation

Name: Date:

Residence:

Reason for Referral:

Current Prescribed Diet Consistency

Current Prescribed Liquid Consistency

History: Medical Diagnoses:

History of Pneumonia (dates):

Oral Hygiene: Appears adequate Appears poor

Dentition: complete missing teeth edentulous dentures

Positioning: Upright independent Upright assisted Reclined Other

Adaptive Equipment:

Eating style : Feeds self Requires physical assistance Fed

Oral Motor Skills WNL Problem Noted Comments

Lips-- Appearance Purse Retraction Symmetry Tongue-- Appearance Protrusion Retraction Lateralization Resting Position Dentition-- Appearance Occlusion Missing teeth Dentures Bite Reflex Alveolus Velum- Appearance Gag reflex During phonation Respiration Mandible Nasal cavity/septum DDS Health Standard # 07-01 Guidelines for Identification and Management of Dysphagia and Swallowing Risks 1 Attachment D, sample, Swallowing Evaluation- Speech Language Pathologist Name: Date:

Swallowing WNL Problem Noted Comments Feeding rate Bolus size Lip closure Ability to clear utensil Chewing Tongue pumping Control of bolus Oral transit time Residue-- Tongue Palate Anterior sulcus Lateral sulci Initiation of swallow Elevation of larynx Head or neck posturing Painful swallows Regurgitation

Clinical Aspiration Symptoms:

Coughing Gurgly voice Regurgitation Eye tearing

Wet breath sounds Excessive secretions Choking

Comments:

Recommendations:

No difficulty noted. No further evaluation necessary Continue present food and liquid consistencies Modify food consistency to: Modify liquid consistency to: Modified Barium Swallow (MBS) Other:

Speech/Language Pathologist

DDS Health Standard # 07-01 Guidelines for Identification and Management of Dysphagia and Swallowing Risks 2 Attachment D, sample, Swallowing Evaluation- Speech Language Pathologist