Swallowing Disorder (Dysphagia) Intake Form
Patient Information
Full Name
Date of Birth
Phone Number
Email Address
Address
Medical History
Primary Diagnosis/Reason for Referral
Relevant Medical Conditions (e.g., stroke, Parkinson’s, etc.)
Current Medications
Allergies
Swallowing Concerns
Onset of Swallowing Difficulty
Specific Foods/Textures Causing Difficulty
Swallowing Symptoms
Coughing during/after eating
Choking
Wet/gurgly voice
Pain while swallowing
Frequent throat clearing
Food sticking in throat
Unexplained weight loss
Other Symptoms
Diet & Nutrition
Current Diet (e.g., regular, pureed, etc.)
Type of Liquids Consumed (e.g., thin, thickened, etc.)
Do you require assistance with feeding?
No
Sometimes
Always
Additional Information
Goals for Therapy/Assessment
Any Additional Comments or Questions