Feeding and Swallowing Checklist
Feeding and Swallowing Checklist
Feeding and Swallowing Checklist
Client Name:
Date of Birth:
Relationship to Client:
Date Completed:
Please make sure the client is involved in completing this checklist in accordance
with their ability and wishes
This is not an assessment or a risk assessment but is intended to help you identify the
need to contact a Speech and Language Therapist.
Please read the instructions carefully at the top of each section and
contact the Speech and Language Therapy Department if you need
further help.
- Insert address -
PLEASE NOTE:
In the event of the person choking, it is presumed that first aid
policies / procedures will be followed as necessary.
Client DOB:
Section 1: Please read statements 1 – 17 below and tick the box where appropriate to
represent the individual named on the front page
If you tick a shaded box, please contact the Speech and Language Therapy Department for advice .
Occasionally
Don’t know
Every Day
No Description
Never
1 He / She coughs or splutters during or after eating or drinking
2 His / Her breathing sounds different (e.g. ‘rattly’) after eating or drinking
3 His / Her voice sounds different (e.g. ‘wet’ or ‘gurgly’) after eating or
drinking
9 He / She drools
12 He / She loses food or drink from the mouth or nose whilst eating or
drinking
15 He / She holds food or drink in the mouth for a long time before
swallowing
Section 2: Please read statements 19 – 23 below and tick the box where appropriate to
show how often it happens
If you tick a shaded box, please contact the Speech and Language Therapy Department for advice.
Please outline in the space below any other concerns, relevant past history or recent changes regarding
the person’s eating, drinking or swallowing.