Response to thickened liquids__________________________________________________________________________ Recommendations___________________________________________________________________________________ SWALLOWING CONCERNS: pneumonia or history of pneumonia gagging □ □ delayed swallow coughing □ □ multiple swallows wet voice □ □ chronic low grade fever congestion □ □ chronic, copious, clear secretions concerns related to weight □ □ oral cavity not clear after swallow tongue pumping □ □ larynx does not elevate properly □ RESPONSE TO FEEDING: alert throughout lethargic irritable □ □ □ facial grimacing anxious irregular or audible breathing □ □ □ refusal vomiting increased hypertonicity □ □ □ reflux fatigue facial reddening □ □ □ Other________________________________________________________________________ ________________________________________ ________________________________________________ Completed Completed by/Title D21 Feeding and Swallowing Evaluation Positioning for Feeding: Checklist: ____ Body symmetrical ____ Head upright ____ Arms supported ____ Pelvis anchored and squared ____ Hips flexed at 90 degrees ____ Thighs separated
Response to thickened liquids__________________________________________________________________________ Recommendations___________________________________________________________________________________ SWALLOWING CONCERNS: □ pneumonia or history of pneumonia □ gagging □ delayed swallow □ coughing □ multiple swallows □ wet voice □ chronic low grade fever □ congestion □ chronic, copious, clear secretions □ concerns related to weight □ oral cavity not clear after swallow □ tongue pumping □ larynx does not elevate properly RESPONSE TO FEEDING: □ alert throughout □ lethargic □ irritable □ facial grimacing □ anxious □ irregular or audible breathing □ refusal □ vomiting □ increased hypertonicity □ reflux □ fatigue □ facial reddening Other________________________________________________________________________ ________________________________________ ________________________________________________ Completed Completed by/Title D21 Feeding and Swallowing Evaluation Positioning for Feeding: Checklist: ____ Body symmetrical ____ Head upright ____ Arms supported ____ Pelvis anchored and squared ____ Hips flexed at 90 degrees ____ Thighs separated
slp_manual__fall_2014.docx