Appendix 3.1
APPENDIX 3.1
History gathering cheat sheet. This format may be used to aid in note taking during the interview process.
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Starter Questions: (completed before the interview. May be based on available pre-evaluation history or self-report forms that were completed in the waiting room) 1. 2. 3. 4. Future Questions: (make notes for areas that require follow up.)
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Content Areas: (use this section to make notes about content areas and identify areas that require further investigation) ONSET of PROBLEM
TIMELINE of SWALLOW DEFICITS
CONSISTENCY of SWALLOW DEFICITS
Better? Worse?
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Signs / Symptoms / Red Flags: (use this section to make notes during interview about dysphagia symptoms)
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Current diet or Recent diet changes: (use this section to make notes about dysphagia symptoms)
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Other Notes:
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