Fiberoptic Endoscopic Swallowing Evaluation Form
Please provide the following information to support the fiberoptic endoscopic swallowing evaluation.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referring Provider Name
*
Reason for Referral
*
Relevant Medical History (e.g., neurological, respiratory, ENT conditions)
*
Current Swallowing Symptoms
*
Coughing or choking during meals
Wet or gurgly voice after swallowing
Difficulty chewing
Food or liquid sticking in throat
Unintentional weight loss
Other
Current Medications
Known Allergies
Baseline Oral Intake Status
*
Normal diet
Modified texture diet
Tube feeding
NPO (nothing by mouth)
Other
Previous Swallowing Evaluations or Interventions
Submit Evaluation
Should be Empty: