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Practice name: ______________________________
Swallowing & Dysphagia Assessment Form
Your information
Full Name *
Referring Provider
Relevant Medical History
Current Diet Texture Level
Swallowing Trials - Thin Liquids
Additional details
Swallowing Trials - Puree/Soft
Swallowing Trials - Regular Solids
Clinical Signs of Aspiration
Pulse Oximetry Readings
Clinician Signature
Date
Swallowing & Dysphagia Assessment Form template from formisoft.com. formisoft.com/intake-templates/dysphagia-assessment