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Get ASHA Clinical Swallowing Exam

relevant medical history/diagnoses/surgery Medications: Allergies: Pain: Primary languages spoken: Educational history: Occupation: Hearing status: Vision status: Tracheostomy: Mechanical ventilation: Subjective/Patient Report: Symptoms reported by patient (check all that apply): __Drooling __Coughing __Choking __Difficulty swallowing: __Solids __Liquids __Pills __Pain on swallowing __Food gets stuck __Weight loss __History of aspiration or pneumonia ______________________ __Other: ___________.

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