Mobile Dysphagia Consultants

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Facility Name *

City *

State *
CT
MA
NH
ME
RI

Facility Phone *
  

(Phone with area code)       Extension

Dept.

Scheduling Contact Phone *

(Phone with area code)
Treating SLP/OT *

First and Last Name
SLP Cell Phone *

(Phone with area code)
Contact SLP via text?
Yes
No

Patient Name *

First and Last Name
DOB *
MM/DD/YYYY
Sex *
Female
Male

Height
Feet and Inches

Weight

SS #

Room/Unit #

Verbal Consent *
Patient
Health Care Proxy

Health Care Proxy, if applicable

First and Last Name
Name of Staff Member Receiving Consent *

First and Last Name
Skilled Stay? *
Yes
No

Medicare #

Name of Other Policy

Other Policy #

Medicaid - Indicate State

Medicaid #

Ordering Physician *

First and Last Name
Reason(s)Mobile/Onsite Visit 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 participant

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

Other

Respiratory Status *
WFL
0-2
Vent
Speaking Valve

Trach Type

Trach Size

Contact Precautions *
Yes
No

List Precautions

Food Allergies *
Yes
No

List Allergies

Medical Necessity for Consult
Check if applicable
Breathing difficulty w/PO intake
Coughing
Choking
Dehydration
Feeding Difficulties
Food/pills getting stuck
Gagging
Esophageal Reflux
Globus Sensation
Heartburn
Malnutrition
Moist Cough
Pain on Swallowing
Pneumonia
Poor PO Intake
Respiratory distress
Shortness of breath
S/S of silent aspiration
Tearing with oral intake
Vomitting
Weight Loss
Wet vocal quality
Wheezing with PO intake
Other

Other

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 *
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
Liquids *

Solids *

Trials

Current Strategies

Scheduling Restrictions

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