Swallowing & Dysphagia Assessment Form

The Swallowing & Dysphagia Assessment Form provides speech-language pathologists and clinicians with a structured clinical bedside evaluation tool for identifying swallowing dysfunction and aspiration risk. It captures a thorough oral motor examination including labial seal, lingual range of motion and strength, velar elevation, laryngeal excursion on palpation, and volitional cough strength. The cranial nerve assessment section evaluates CN V (trigeminal), CN VII (facial), CN IX (glossopharyngeal), CN X (vagus), and CN XII (hypoglossal) function as they relate to the oral preparatory, oral propulsive, pharyngeal, and esophageal phases of swallowing.

This template incorporates the International Dysphagia Diet Standardisation Initiative (IDDSI) framework for documenting swallowing trial results across standardized food texture levels (Level 3 Liquidised through Level 7 Regular) and drink thickness levels (Level 0 Thin through Level 4 Extremely Thick). It records clinical signs of aspiration during trials including coughing, throat clearing, wet/gurgly vocal quality, delayed swallow initiation, and oral residue, along with pulse oximetry desaturation monitoring. The form also captures relevant medical history factors that increase aspiration risk including stroke, traumatic brain injury, head and neck cancer treatment, neurodegenerative disease, prolonged intubation, and tracheostomy status.

Designed for acute care hospitals, skilled nursing facilities, outpatient speech-language pathology clinics, and home health agencies, this form supports documentation requirements for instrumental swallowing study referrals (videofluoroscopic swallow study or fiberoptic endoscopic evaluation of swallowing) and justifies modified diet texture recommendations. It aligns with ASHA documentation standards and CMS requirements for skilled speech-language pathology services related to dysphagia management.