INTERDISCIPLINARY CONSULTATION by vlq27948

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									                 INTERDISCIPLINARY CONSULTATION
          FEEDING / SWALLOWING OBSERVATION / EVALUATION

                                                     Date of Consultation:

   Student:                                        Age:                  Date of Birth:
   Diagnosis:                    Exceptionality:                           Physician:
   School:                                         Classroom Teacher:
   SLP:                       OT:                             Nurse:

   Medical History:



GENERAL INFORMATION
 During this consultation the student was:
   Seating                 Student Position        Food Presented by             Utensils Used
     Wheelchair               Upright                 Classroom teacher             Bottle
     Tumble form              Semi upright            Paraprofessional              Sippy cup
     Rifton Chair             Reclining <30º          Parent                        Cup
     Other:                   Other:                  Other:                        Spoon
     Normal chair                                    self                           Straw

GENERAL OBSERVATIONS
   Behavior                Alertness               Follows directions            Vision
     Cooperative             Alert                    Verbal                       Mild impairment
     Resistant               Lethargic                Gestural                     Moderate impairment
     Refusal                 Irritable                None                         Severe impairment
     Other                   Other                    Single step only


GENERAL PHYSICAL OBSERVATIONS
  Abnormal reflexes observed:

   Trunk                 Head Control                Facial                        Breathing Patterns
     Excessive extension    Adequate                    Asymmetrical                  Mouth breather
     Dystonia               Poor                        Contortions                   Audible inhalation
     Scoliosis              Excessive head/             Jaw extension
     Kyphotic               neck hyper                  Grimaces/tics
     Asymmetric             extension                   Open mouth posture
                                                        Increase tone
                                                        Decrease tone
OBSERVATION OF FEEDING
  Food consistencies
    Pureed                   Bite size
    Ground                   Mixed (indicate consistencies of
    Mashed                   mixtures)
    Chopped


  Food presented during evaluation:



                                                Indicate food   Indicate observed Additional
                                                consistency     behaviors         observations

  Accepts food
  Lips
        Poor lip closure
        Drooling
        Licks lips clean
  Tongue
        Poor bolus formation/movement
        Decrease anterior/posterior movement
        Food residue
  Rotary jaw movement
  Munching jaw movement
  Initiates a swallow
  Swallow delay
  Cough following a swallow
        Increased clearing throat
  Residual food in oral cavity
  Cued swallow
  Fatigues easily

OBSERVATION OF DRINKING
  Liquid consistencies
    Unthickened
    Nectar
    Honey
    Pudding

  Liquid presented during evaluation:
                            Indicate liquid      Indicate observed Additional
                            consistency          behaviors         observations
Tongue thrust
Tongue retraction
Anterior loss
Appropriate jaw opening
Upper lip closes over cup
Delayed swallow
Coughing following drink

  ADDITIONAL COMMENTS




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INTERDISCIPLINARY CONSULTATION CONDUCTED BY:


   Speech Language Pathologist


   Occupational Therapist


   Nurse

   ADDITIONAL PARTICIPANTS
   Signature                                  Title




                                                                              Reprinted by permission:
                                                      St. Tammany Parish Schools Dysphagia Team 9/06

								
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