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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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Keywords relevant to ASHA VFSS Template

  • WNL
  • pureed
  • velopharyngeal
  • NPO
  • Hyolaryngeal
  • otolaryngology
  • Videofluoroscopic
  • nasogastric
  • oropharyngeal
  • Effortful
  • GASTROSTOMY
  • Pulmonology
  • pharyngoesophageal
  • NOMS
  • Jejunostomy
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