Medical History

• admit diagnosis
• functional problems observed
• level of alertness
• previous diagnoses and treatment
• advance directive
• premorbid status

Referral

• reason for referral
• signed physician's order

Signs & symptoms of dysphagia

• temperatures
• drooling/increased secretions
• weight loss
• coughing/choking
• pocketing
• pneumonia
• changes in diet
• patient complaint
• dehydration
• reflux

Nutrition/Hydration

• current diet
• dietary restrictions
• alternate method of feeding

Medications

• sedatives
• antibiotics
• how presented to patient

Respiratory Status

• lung sounds
• chest x-rays
• oxygen therapy and mode of delivery
• recent intubations
• tracheostomy/type
• ventilator
• status of cuff
• tracheostomy speaking valve

Nursing assessment

• cognitive/communicative assessment
• temperature
• observations of patient
• previous living situation
• family support/involvement
• sensory impairments

Other evaluations

• GI series
• Ba swallow
• neurological consult
• dietary consult