Name ‘Age —_ Gender ___ Room —__ Birth Date . re Evaluation Dat: Swallowing Ability and | sagnoas Function Evaluation Date of Onset Pscan fain Profile/Examiner Record Form 1. Physical Examination (PE) 2. Oral Phase (OP) Subscale Score ile Stanine 3. Pharyngeal Phase (PP) = Stanine Rehabilitation Recommendations and Potential hatte one ot on an copra © 205 OED ne eee mot ron sha GeSection IV, Record of Items and subscale Pe} a_i ee Scorn Ceri: (With finctonal mits @) Mid impatment (1) Moderate impairment _(0) Severe impairment ‘Scoring Cita: () Within funtion Its ox svalloning ort preblematc ©) Not funcional forswalowina or problematic STAGE 1 Subscale 1: Physical Examination of Oropharyngeal Mechanism Physical Examination of Oropharyngeal Mechanism i els ar eles s AU Bd ou HEAPS aE E Io im a a = os s = Es ala Oral reflexes Physical Examination (PE) Total 7 STAGE 2 Subscale 2: Oral Phase Swallowing Evaluation [Symptom ‘Score (0, 1,2, 3) | } [Consistency reticnt| Lip cosire Thiniiguds pseal Thick liquids Pocketing Bolus transport Nunibe of ewallows per bolus Ratesvength of mastication Nasal reputation al Pase (OP Ta Subscale 3: Pharyngeal Phase Swallowing Evalustion = Score 0,1,2.3) Delo at pharyged bel (seconds) angel evaon Ege Poiva beater re maton Repeated swallows Complanis of food beng “stuck” Hoase/aurayhnet voice folowing swallow (cle one) Regurataten/erpedtoration of food Pharyigeal Phase PP) Total STAGE 3, Auscultation and/or Additional Noter Abit to fob nsvacions S| it orate Endurance