Contact Email*

Contact Phone Number*

Client Full Name*

What specific swallowing concerns are being observed (e.g., coughing, choking on solids, choking on saliva, choking on liquids, food refusal, prolonged mealtimes), inability to eat desired foods?

When did the swallowing difficulties begin, and have they changed over time?

Are difficulties noted with specific food textures or liquids?

Any history of aspiration, chest infections, pneumonia, or weight loss?

Relevant medical history (e.g., neurological conditions, reflux, gastritis, respiratory issues, head/neck surgery)?

Current diet and fluid consistencies (including any modifications already in place)?

Any previous swallowing assessments or involvement from other health professionals?

Current mealtime supports, strategies, or equipment being used:

Any behavioural or sensory factors impacting mealtimes?

Can the client attend the assessment at the clinic, or will the therapist need to travel to the client’s accommodation?
If travel is required, please outline the reason.

* = Required field

Δ