Appendix 2 Swallowing Assessment Tool
| Name: | Address: | Date of Birth: | |||
| GP Name: | Surgery: | Number: | |||
| Assessor Name: | Organisation: | Number: | |||
| Date of Assessment: | Review Date: |
Medical Diagnosis (tick all relevant):
| Dementia | √ | Stroke | √ |
| Epilepsy | Traumatic Brain Injury | ||
| General Deterioration | Respiratory Disorder (Asthma/COPD) | ||
| Gastro/Digestive Disorder (Hiatus Hernia/Reflux) | Progressive Neurological Condition (MND/PD/MS) | ||
| Cognitive Impairment | |||
| Other (including Mental Health Condition) please state: | |||
Current Diet/Fluids (tick all relevant):
| Normal Diet | Pureed Food | ||
| Soft (Normal Diet) | Normal/any fluids | ||
| Mashable (with bread) | Thickened Fluids (please state which stage) | ||
| Mashable (NO BREAD) | Non-Oral feed (PEG) | ||
| Describe any difficulties with current Oral intake: | |||
Medication:
| Gastric Medication | |
| Anti-Psychotics | |
| Alendronic Acid | |
| Adcal | |
| Supplements |
Observations: (tick all relevant):
| Coughing on eating/drinking |
High Risk!! Please refer to SALT when any box is ticked. |
|
| Weak cough/ineffective in clearing throat | ||
| Has required urgent attention when eating/drinking | ||
| Recurrent Chest Infections | ||
| Current Chest Infection | ||
| Wet, gurgling voice while eating/drinking | ||
| Thickened Fluids (without SALT input) | ||
| Complains food sticks in the throat | ||
| Short of Breath/changes to breathing after eating/drinking |
| Unexplained weight loss |
Medium Risk! Consider referral to SALT when two or more boxes are ticked. |
|
| Known to aspirate (but has strategies from previous SALT input) | ||
| Poor posture/head control | ||
| Trouble swallowing tablets | ||
| Eats/drinks rapidly | ||
| Holding food/drink in the mouth | ||
| Poor/deterioration in physical health | ||
| Food/drink spilling from the mouth | ||
| Swallowing food without chewing/difficulty chewing |
| Very slow eating |
Low Risk! Consider referral to SALT if three or more boxes are ticked. |
|
| Confusion/disorientation | ||
| Breathing difficulties | ||
| Frequent dehydration/frequent Urinary Tract Infections | ||
| Needs full assistance to eat/drink | ||
| Needs some assistance to eat/drink | ||
| Needs supervision when eating/drinking | ||
| Needs food to be cut up or preparing prior to consumption | ||
| Takes food from others/cupboards if unsupervised | ||
| Difficulty accepting food items in the mouth | ||
| Requires specialist feeding aids (specialised utensils/cups) | ||
| Agitated/anxious at meal/snack times | ||
| Has no dentures/limited number of teeth |
Please give a brief description of any eating/drinking difficulties.
This tool is to be used as a guide only. Any concerns should be referred to SALT for Assessment. If Service User has been seen by SALT and their risk factors have changed, please contact SALT to re-refer
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