Outpatient Rehabilitative Services

Harford Memorial Hospital
501 South Union Avenue
Havre de Grace, MD 21078
443-843-5331		 Physicians Pavilion II
Suite 514
510 Upper Chesapeake Drive
Bel Air, MD 21014
443-643-3257		 Sports Medicine & Rehabilitation Center
Y at Abingdon
101 Walter Ward Blvd.
Abingdon, MD 21009
443-409-0051
 
Swallowing Evaluation - Case History Form

Name:
Date of Birth: (Month/Day/Year) - -    Age:
Primary Doctor:
Referring Doctor
(If different from above)

Medical History
Cardiac Bypass Surgery Anterior Cervical Fusion Dementia
Arthritis Diabetes High Blood Pressure
Cancer  Stroke Feeding Tube
Neurological Impairment, i.e.:
(ALS, Parkinson’s, M.S.)		 Intubation / # of Days Previous Swallowing Exam or Therapy
Multiple Pneumonias Dehydration / Malnutrition Visit with Ear, Nose, Throat Dr.
Thyroid Disease / Surgery Esophageal Stretching  Changes in Voice or Speech
Chronic Dry Mouth Breathing Difficulty Tracheotomy
Psychological Concerns  i.e. Depression, Bipolar, Schizophrenia
   
If any Radiation Treatment, to what part of your body?
 
Describe your swallowing difficulty (be as detailed as possible):
 
How long has this been going on?
 
How do you take your pills?
 
If any Radiation Treatment, to what part of your body?
Describe your swallowing difficulty (be as detailed as possible):

(Maximum characters: 200)
How long has this been going on?
How do you take your pills?
Any trouble swallowing pills? NO YES
Which do you have the most difficulty? Solids Liquids Both Solids and Liquids
About how long does it take you to eat a meal?
Any trouble with chewing food?
How is your appetite? Excellent Good Fair Poor
Have you been losing weight? NO YES
Gaining Weight? NO YES     If so, how much?
What texture of foods / liquids do you eat now? Regular Soft  Blenderized/Puree
Do you use supplements, such as Ensure or Glucerna? NO YES
Describe your teeth: Natural / Good condition?
  Natural / Scattered
  Dentures: Full upper
  Full lower
  Partial upper
  Partial lower
  If dentures, do they fit well?

Current Medication List:
Name Dose Frequency

Do you have any of the following ? If so please check all that apply:
Interrupted Sleep Gastroesophageal Reflux (GERD) Hiatal Hernia
Dry or Sore Throat Bad Breath Painful Swallowing
Repeated Swallowing Belching or Hiccupping Increased Salivation
Chronic Asthma Lightheaded or Faint Bloating
Choking Sensation Vomiting Loss of Voice
Regurgitation of Undigested Food Jaw Pain Chronic Cough
Spasms of the Throat or
Voice Box		 Aspiration (the entry of foreign material or secretions into the airway) Acidic, Metallic or Sour taste in back of throat or mouth
Neck Pain Ear Pain Pain inside mouth

Within the last MONTH, how did the following
problems affect you?

 0= No Problem
5= Severe Problem
 
0
1
2
3
4
5
Hoarseness or a problem with your voice
Clearing your throat
Excess throat mucous or post nasal drip
Difficulty swallowing food, liquids or pills
Coughing after you ate or lying down
Breathing difficulties or choking episodes
Troublesome or annoying cough
Sensation of something sticking in your throat or a lump in your throat
Heartburn, chest pain, indigestion, or stomach acid coming up


Anything else in your background, or why you were referred that you think we should know to better evaluate you?

(Maximum characters: 200)

Thank You!
Speech Pathology Dept of the Upper Chesapeake Health System
Questions? Please call:
443-643-1801-Upper Chesapeake Medical Center
443-843-5331-Harford Memorial Hospital