Mobile Dysphagia Consultants

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Exam to be Scheduled At *
Private Residence
Assisted Living Facility
Dayhab
Group Home
Other

Facility Name (if applicable)

Street Address *

Apartment/Bldg/Unit

City *

State *

Scheduling Contact*
First NameLast Name

Relationship to Patient

Primary Contact # *

Secondary Contact # *

Medicare
Medicare Part A
Medicare Part B

Medicare #

Medicaid - Indicate State

Medicaid #

Other Policy

Other Policy #

Patient Name *
First NameLast Name

DOB *
MM      DD       YYYY

Sex *
Female
Male

Height
Feet and Inches

Weight

Social Security #

Can Patient Consent for Self? *
Yes
No

Health Care Proxy Invoked *
Yes
No

Treating SLP/OT/RN Name
First NameLast Name

Cell #

Prefer Text?
Yes
No

Best Contact #

Email

Agency

Agency Address

Ordering Physician *
First NameLast Name

Practice Name *

Practice Address *

Practice Phone # *

Reason(s) for Mobile/Onsite Visit is Required *
Emergent request due to elevated aspiration risk
Transport negatively impacts underlying physical condition
Fatigues easily, compromising test participation
Transport exacerbates behavioral problems and compromises test participation

Medical History *
CVA
CHF
COPD
Developmental Delays
Intellectual Impairment
Parkinson's
GERD
Alzheimer's
Dementia
Pneumonia
TBI/CHI
Head/neck cancer
Other

Other History

Medical Necessity for Consult*
Breathing difficulty w/ PO intake
Pain on swallowing
Coughing
Pneumonia
Choking
Poor PO intake
Dehydration
Respiratory distress
Feeding difficulties
Shortness of breath
Food/pills getting stuck
S/S of silent aspiration
Gagging
Tearing with oral intake
Esophageal_reflux
Vomiting
Globus sensation
Weight loss
Heartburn
Wet vocal quality
Malnutrition
Wheezing with PO intake
Moist cough
Other

Other

Respiratory Status *
WFL
0-2
Vent
Speaking Valve
Trach

Trach Type

Trach Size

Contact Precautions *
Yes
No

List Precautions

Food Allergies *
Yes
No

List Allergies

Duration of Symptoms *
New Onset
Days
Weeks
Months

Frequency of Symptoms *
All PO
Liquids
Solids
Pills
Saliva
Other

Other

Other Goals *
Determine least restrictive diet
Determine safest diet
Pre-treatment evaluation
Determine appropriate swallow maneuvers/strategies

Status Change Due To *
Weight Loss
Malnutrition
Pneumonia
Reduced PO
Increased Awareness
Descreased Awareness
Improved Swallowing
Decline in Swallowing

Swallowing Treatment *
Not on caseload for dysphagia
New Evaluation
E-Stim
Thermal Stim
O-M ex.
Pharyngeal ex.

Candidate for Strategies *
Yes
No

Current Diet *
NPO
Gtube
Jtube
NGT
Solids
Liquids
Trials

Liquids

Solids

Trials

Current Strategies

Scheduling Restrictions

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