<p> Department of Developmental Services</p><p>Swallowing Evaluation</p><p>Name: Date: </p><p>Residence: </p><p>Reason for Referral: </p><p>Current Prescribed Diet Consistency </p><p>Current Prescribed Liquid Consistency </p><p>History: Medical Diagnoses: </p><p>History of Pneumonia (dates): </p><p>Oral Hygiene: Appears adequate Appears poor</p><p>Dentition: complete missing teeth edentulous dentures</p><p>Positioning: Upright independent Upright assisted Reclined Other</p><p>Adaptive Equipment: </p><p>Eating style : Feeds self Requires physical assistance Fed</p><p>Oral Motor Skills WNL Problem Noted Comments</p><p>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: </p><p>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 </p><p>Clinical Aspiration Symptoms:</p><p>Coughing Gurgly voice Regurgitation Eye tearing </p><p>Wet breath sounds Excessive secretions Choking</p><p>Comments:</p><p>Recommendations:</p><p>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: </p><p>Speech/Language Pathologist</p><p>DDS Health Standard # 07-01 Guidelines for Identification and Management of Dysphagia and Swallowing Risks 2 Attachment D, sample, Swallowing Evaluation- Speech Language Pathologist</p>