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Swallowing & Dysphagia Assessment Form

Asks about referring provider, relevant medical history, and current diet texture level. Built for acute care bedside swallowing evaluation following stroke, intubation, or head/neck surgery.

Questions
14
Pages
2
Time
about 4 min

Includes

  • E-signature
  • Conditions checklist
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Your practice

Swallowing & Dysphagia Assessment Form

Page 1 of 2 · Your information

Live preview. Tap through it like a patient.

Who it is for

  • Acute care bedside swallowing evaluation following stroke, intubation, or head/neck surgery
  • Skilled nursing facility dysphagia screening and diet texture level determination
  • Pre-referral documentation for videofluoroscopic swallow study (VFSS) or FEES evaluation
  • Serial dysphagia reassessment for diet texture upgrade progression in rehabilitation patients

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What's inside

Before you publish: Clinical review required: this worksheet does not calculate scores, diagnose, or recommend treatment. Confirm the questions and response options against your approved assessment protocol before use.

Page 1 · Your information

  1. Full NameText · Required
  2. Referring ProviderText
  3. Relevant Medical HistoryConditions
  4. Current Diet Texture LevelLong Text
  5. Oral Motor ExaminationLong Text

Page 2 · Additional details

  1. Swallowing Trials - Puree/SoftLong Text
  2. Swallowing Trials - Regular SolidsLong Text
  3. Clinical Signs of AspirationLong Text
  4. Pulse Oximetry ReadingsText
  5. IDDSI Diet RecommendationLong Text

From form to a ready patient

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    Make it yours

    Reword, reorder, or add to the Swallowing & Dysphagia Assessment Form, and add your logo.

  2. A patient filling out a Formisoft form on a phone

    02

    Patients finish it at home

    A secure link by text or email, filled out on their phone before the visit. No app.

  3. The Formisoft dashboard showing how many of today's patients are ready

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    Your team sees who is ready

    Each visit shows as ready once its forms are in. Answers land on the patient record.

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Questions

Formisoft provides secure form collection and a Business Associate Agreement (BAA). Your practice must review the form content, access permissions, and sharing workflow for its requirements.

Yes. You can add, remove, reorder, or reword any of the 14 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Patients open a secure link from an email, a text, or a QR code and complete the form on their phone, tablet, or computer before their appointment. No app download required.

Yes, on Front Desk. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Yes. The Swallowing & Dysphagia Assessment Form works on any device. Most patients complete intake forms on their phone, so every template is built for small screens first.

Send it before the visit, so patients arrive ready.

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