REASON FOR REFERRAL (Please tick as appropriate) Swallowing □ What are the current diet and fluid recommendations? Please tick: Normal fluids diet □ Normal □ Easy chew Pre-Stage 1 □ □ Fork mashable Stage 1 □ □ Pre mashed Stage 2 □ □ Pureed □ Other (please state recommendations below): What are the swallowing symptoms? Please tick: Coughing/ choking on food Coughing/ choking on fluids □ □ Pocketing food Leaving food/ poor intake □ □ Recurrent chest infection Absent swallow □ □ Other (please state problem below): What is the frequency of the problem? Please tick: Almost every time they have a meal/drink 4-5 times a day □ □ 1-2 times per day Occasional/ one off (choking) □ □ Please ensure resident has been observed and the difficulties recorded above are accurate and all carers are in agreement □ Any other relevant information: Communication □ If communication describe the problem:
REASON FOR REFERRAL (Please tick as appropriate) Swallowing □ What are the current diet and fluid recommendations? Please tick: Normal diet □ Normal fluids □ Easy chew □ Pre-Stage 1 □ Fork mashable □ Stage 1 □ Pre mashed □ Stage 2 □ Pureed □ Other (please state recommendations below): What are the swallowing symptoms? Please tick: Coughing/ choking on food □ Coughing/ choking on fluids □ Pocketing food □ Leaving food/ poor intake □ Recurrent chest infection □ Absent swallow □ Other (please state problem below): What is the frequency of the problem? Please tick: Almost every time they have a meal/drink □ 4-5 times a day □ 1-2 times per day □ Occasional/ one off (choking) □ Please ensure resident has been observed and the difficulties recorded above are accurate and all carers are in agreement □ Any other relevant information: Communication □ If communication describe the problem:
Adult_Speech_and__Language_Therapy_Community_Referral_Form.docx