Dysphagia Care Plan Form
Please complete this form to help us create and manage an effective care plan for swallowing difficulties.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Swallowing Difficulty Status
*
Mild
Moderate
Severe
Recommended Food Texture
*
Please Select
Regular
Soft
Minced & Moist
Pureed
Recommended Liquid Consistency
*
Please Select
Thin
Nectar-thick
Honey-thick
Pudding-thick
Mealtime Instructions
*
Diet Restrictions or Allergies
History of Choking or Aspiration
*
No history
Occasional incidents
Frequent incidents
Feeding Support Required
*
Self-feeding
Assisted feeding
Feeding tube
Other
Medication Swallowing Concerns
Clinician Notes
Submit Care Plan
Should be Empty: