Dysphagia Evaluation

Patient's Information

Patient's Name:	[Patient's Name]
Date of Birth:	[Patient's Date of Birth]
Gender:	[Patient's Gender]
Evaluator's Name:	[Evaluator's Name]
Date:	January 20, 2055

Purpose: This evaluation aims to assess swallowing function comprehensively, identifying any impairments or abnormalities that may impact an individual's ability to swallow safely and effectively.

Overview: The evaluation will assess various aspects of swallowing function, including the oral, pharyngeal, and esophageal phases. Specific criteria will be evaluated within each phase to provide a comprehensive understanding of the individual's swallowing abilities. The evaluation aims to identify any impairments, risks of aspiration, and potential interventions to improve swallowing function and quality of life.

Instructions: Please review each criterion on the evaluation form and assess the individual's swallowing function accordingly. Provide additional comments or observations as needed. Use the rating scale to indicate the player's proficiency in each area:

0: No impairment or dysfunction observed.
1: Mild impairment or dysfunction observed.
2: Moderate impairment or dysfunction observed.
3: Severe impairment or dysfunction observed.

Oral Phase

Criteria	Description	0	1	2	3
Lip Closure	Adequacy of lip seal during swallowing
Tongue Movement	Range and coordination of tongue movement
Bolus Formation	Ability to form a cohesive bolus
Oral Transit Time	Time taken for bolus movement through the mouth
Coordination	Coordination of oral structures during swallowing

Pharyngeal Phase

Criteria	Description	0	1	2	3
Pharyngeal Swallow Reflex	Initiation and strength of pharyngeal swallow reflex
Swallowing Timing	Timing and coordination of swallowing phases
Pharyngeal Clearance	Efficiency of clearing bolus from pharynx
Laryngeal Closure	Effectiveness of laryngeal closure during swallowing
Upper Esophageal Sphincter	Integrity and relaxation of the upper esophageal sphincter

Esophageal Phase

Criteria	Description	0	1	2	3
Esophageal Peristalsis	Coordination and strength of esophageal peristalsis
Bolus Passage	Efficiency of bolus passage through the esophagus
Lower Esophageal Sphincter	Integrity and relaxation of lower esophageal sphincter

Aspiration Risk

Criteria	Description	0	1	2	3
Coughing	Frequency and severity of coughing episodes
Choking	Incidence of choking episodes during swallowing
Respiratory Distress	Signs of respiratory distress following swallowing

Drooling

Criteria	Description	0	1	2	3
Severity	Severity of drooling
Frequency	Frequency of drooling episodes

Mealtime Behaviors

Criteria	Description	0	1	2	3
Food Refusal	Frequency of refusing food during mealtimes
Avoidance of Certain Foods	Extent of avoiding specific food textures or consistencies
Prolonged Mealtime	Duration of mealtime compared to typical norms

Quality of Life

Criteria	Description	0	1	2	3
Social Impact	Impact of dysphagia on social interactions
Emotional Impact	Emotional effects of dysphagia on the individual
Functional Impact	Impact of dysphagia on daily activities and function

Dysphagia Evaluation

Dysphagia Evaluation

Patient's Information

Oral Phase

Pharyngeal Phase

Esophageal Phase

Aspiration Risk

Drooling

Mealtime Behaviors

Quality of Life

Additional Notes and Comments: