Bedside Swallow Evaluation Form
Complete this form to document a bedside swallow evaluation, including patient details, screening observations, and next-step recommendations.
Patient and Evaluation Details
Patient Name
*
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Evaluation
*
Hour Minutes
AM
PM
AM/PM Option
Referring Clinician or Department
Evaluator Name / Role
*
Swallow Screening Observations
Reason for Evaluation
Current Diet or Feeding Status
*
Please Select
NPO
Oral diet
Tube feeding
Other
Alertness and Ability to Follow Directions
*
Alert and cooperative
Drowsy but arousable
Inconsistent response to directions
Unable to follow directions
Signs Observed During Bedside Swallow Attempt
Coughing
Throat clearing
Wet or gurgly voice
Prolonged oral holding
Drooling
No overt signs observed
Summary and Next Steps
Clinical Impression or Recommendations
*
Recommended Next Step
*
Please Select
Continue current plan
Modify diet
Supervise meals
Further instrumental assessment
Other
Submit Bedside Swallow Evaluation Form
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