Clinical Evaluation of Motor Speech and Swallowing Protocol 1

Clinical Evaluation of Motor Speech and Swallowing Protocol

Patient: _______________________________________________
Patient ID #:
_____________________________________________
Evaluation Date:
_________________________________________
Date of Birth:
____________________________________________
Referral:
________________________________________________

Medical Diagnosis:
_______________________________________
Date of Onset:
___________________________________________
Secondary Diagnosis:
______________________________________
Date of Onset:
__________________________________________

PATIENT HISTORY
Reason(s) for Referral:
_____________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Surgeries:
_______________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Medications:
____________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Hearing
Status:___________________________________________________________________________________________________________
Vision
Status:____________________________________________________________________________________________________________
Allergies:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Educational/Vocational History:
_____________________________________________________________________________________________
________________________________________________________________________________________________________________________
Other Medical Diagnosis
____________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Yes/N
o

# of
Occurrences in
Past year

Additional Comments

History of
Aspiration
History of
Pneumonia
Weight Loss

History of
speech

# of lbs.:
______
When?

Problem:

Clinical Evaluation of Motor Speech and Swallowing Protocol 2

and/or
language
problems
Other Relevant History:
____________________________________________________________________________________________________
________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________

SUBJECTIVE EVALUATION
Yes/No

When?

What?

(Meals, time of
day)

(Types of food,
saliva)

How often?

Additional Comments

Drooling

Coughing
Choking

Food Sticking
Difficulty
Eating

Stage of Swallow:

Pain with
Eating

Stage of Swallow:

Current Diet
Current
Feeding
Method

Solids
Liquids

_____ Independent
Comments:

_____ Assisted
Comments:

____ Regular (NDD

____ Advanced

____ Mech. Alt.

4)

(NDD 3)

(NDD 2)

____ Thin

____ Nectar

____ Honey

NPO:

_____Yes

_____ Dependent
Comments:

____ Mech. Soft

____ Puree (NDD 1)

____ Pudding

____ H2O protocol

_____No

Date of NPO Order:

Enteral Nutrition:

_____Yes

_____No

Date of Tube Placement:

Type:

______NG Tube

______PEG Tube

_____ G Tube

_____J Tube

_____ Other
(specify)

Clinical Evaluation of Motor Speech and Swallowing Protocol 3

Other Comments/Concerns Regarding Current Diet:
___________________________________________________________________________
________________________________________________________________________________________________________________________
OBJECTIVE EVALUATION
Mental Status Examination (check all that apply)
____ Alert

____ Responsive
Comments:

Comments:

____ Confused

____ Lethargic

Comments:

____ Cooperative
Comments:

____ Combative
Comments:

Comments:

Oral Motor Exam/Cranial Nerve Assessment

Visual Examination of Face and Neck:
____ WNL

____ Asymmetry
Comments:

____ Weakness
Comments:

___ Abnormal
Movements
Comments:

____ Other (specify)

Comments:

Observation of Oral Cavity:

Teeth

Tongue

____ WNL

____ WNL

____ Dentures
Upper:
Lower:
____ Fasciculation
Specify:

General
Appearanc
e

____ WNL

____ Xerostomia
Specify:

____ Missing Teeth

Specify:

____ Deviation
Specify:

____ Deviation of
Uvulae
Specify:

____ Decay
Specify:

___ Discoloration
Specify:

____ Excess
Secretions

Additional
Comments:
Additional
Comments:
____ Lesions
Specify:

Specify:

Observation of Jaw, CN V:
Opening
and
Closing of
Jaw
Lateral
Movemen
t of Jaw
Open/Clos
e Jaw with
Pressure

____ WNL

____ Incoordination

____ Reduced Tone

____ Reduced
Strength

____ Other (specify)

____ WNL

____ Incoordination

____ Reduced Tone

____ Reduced
Strength

____ Other (specify)

____ WNL

____ Incoordination

____ Reduced Tone

____ Reduced
Strength

____ Other (specify)

Labial Examination, CN VII

Pucker/Sm
ile

____ WNL

____ Incoordination

____ Reduced Tone

____ Reduced
Strength

____ Other (specify)

Pucker
with
Resistanc
e

____ WNL

____ Incoordination

____ Reduced Tone

____ Reduced
Strength

____ Other (specify)

Clinical Evaluation of Motor Speech and Swallowing Protocol 4

Lingual Examination, CN XII:

Tongue
Protrusion
and
Retraction
Tongue
Lateralizati
on

____ WNL

____ Incoordination

____ Reduced Range

____ Reduced
Strength

____ Other (specify)

____ WNL

____ Incoordination

____ Reduced Range

____ Reduced
Strength

____ Other (specify)

Lateralizati
on to
Buccal
Cavities
L/R
Lateralizati
on to
Buccal
Cavities
with
Resistance
L/R
Tip of
Tongue
Push
Against
Tongue
Depressor

____ WNL

____ Incoordination

____ Reduced Range

____ Reduced
Strength

____ Other (specify)

____ WNL

____ Incoordination

____ Reduced Range

____ Reduced
Strength

____ Other (specify)

____ WNL

____ Incoordination

____ Reduced Tone

____ Reduced
Strength

____ Other (specify)

Velum Examination, CN IX and X:

Sustained
Vowel

____ WNL

____ Asymmetrical

____ Reduced
Elevation

____ Incoordination

____ Other (specify)

Palatal
Movement
w/ Vowel
Sound
Presence
of Gag
Reflex

____ WNL

____ Asymmetrical

____ Reduced
Elevation

____ Incoordination

____ Other (specify)

____ WNL

____ Delayed reflex

____ Hypersensitivity

____ No reflex

____ Other (specify)

Oral Agility and Intelligibility Examination

/p/

/t/
/k/

/ptk/
Connect
ed
Speech

____ / 3
sec

____ WNL

____ / 3
sec

____ WNL

____ / 3
sec

____ WNL

____ / 3
sec

____ WNL

____ WNL

____ Mildly
Impaired

____
Incoordination

____ Groping

____
Incoordination

____ Groping

____
Incoordination

____ Groping

____
Incoordination

____ Groping

____ Moderately
Impaired

____ Severely
Impaired

____ No action

____ Other
(specify)

____ No action

____ Other
(specify)

____ No action

____ Other
(specify)

____ No action

____ Other
(specify)

____ Profoundly
Impaired

____ Other
(specify)

Clinical Evaluation of Motor Speech and Swallowing Protocol 5

Intelligib
ly

Pre-Feeding Voice Screening

Quality

____ WNL

____ Breathy

____ Hoarse

____ Strained

Volume

____ WNL

____ Too soft

____ Too loud

____ Inconsistent

Intonation

____ WNL

____ Monotone

____ Sing-song

____ Inconsistent

Pre-Feeding Respiratory Evaluation

Breath Support
Supplemental
Oxygen

____ WNL

____ Shallow

____ Labored

____ No

____ Yes
____ Night Only
All Day

Flow Rate:
____

Oral Presentation of Ice Chips/Dry Swallow (place and X in the observed responses)
Trial 1

____ WNL/No Response

____ Choking

____ Coughing

____ Other (specify)

Trial 2

____ WNL/No Response

____ Choking

____ Coughing

____ Other (specify)

Oral Presentation of Liquids and Solids (place an X in the observed responses)

Consistency

Thin

5 mL
10
mL
Cup

Necta
r

Stra
w
5 mL
10
mL
Cup

Hone
y

Stra
w
5 mL
10
mL
Cup

Puree

Smal
l

# of
Trials

WNL

Anterio
r
Spillage

Reduce
d Bolus
Control

Poor
Bolus
Transit

Pocketin
g

Delaye
d
Swallo
w

Coughin
g or
Choking

Change
in Vocal
Quality

Signs
of
Distres
s

Clinical Evaluation of Motor Speech and Swallowing Protocol 6

Med

Solid

Larg
e
Smal
l
Med

Mixed

Larg
e
Smal
l
Med
Larg
e

Additional Presentations and/or Comments:

___________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Post-Feeding Voice Screening
Quality

____ WNL

____ Breathy

____ Hoarse

____ Strained

Volume

____ WNL

____ Too soft

____ Too loud

____ Inconsistent

Intonation

____ WNL

____ Monotone

____ Sing-song

____ Inconsistent

Post-Feeding Respiratory Evaluation

Breath Support

____ WNL

____ Shallow

____ Labored

CLINICAL FINDINGS
Motor Speech
Disorders
Severity

_____Not Affected

_____ Apraxia

______Dysarthria
Specify:

_____Other (Specify)

_____WNL

_____ Mild

_____Moderate

_____ Severe

____ Oral Preparation

____ Oral Transit

____ Pharyngeal

____ Esophageal

____ Mild

____ Moderate

____ Severe

____ Profound

Characterized
By:
Phase(s) of
Swallow
Affected
Severity
Characterized
by:
RECOMMENDATIONS AND GUIDELINES (check all that apply)
Motor Speech

Therapy:

_____Speech Therapy
Duration:

Clinical Evaluation of Motor Speech and Swallowing Protocol 7

Frequency:
Physician
Referral
Assistive
Devices

_____PCP

_____Neurology

_____Otolaryngol
ogy

______Pulmonolog
y

_____Other
(specify)

Swallowing

Severity

____ Oral Preparation

____ Oral Transit

____ Pharyngeal

____ Esophageal

____ Mild

____ Moderate

____ Severe

____ Profound

Characterized
by:
Add recommendations for motor speech- motor speech

Physician Referral:
____ Pulmonology

____ PCP

Instrumental Assessment:

____ MBSS

____ ENT

____ GI

____ FEES

Dietary Modifications: ____ Solids (specify):

_______________________________________________________________________________
____ Liquids (specify):
______________________________________________________________________________
____ NPO
Supervision:

____ 1:1

____ Intermittent

Meal Precautions:

____ Upright > 30min

____ Small Bites

____ Small Sips

Swallowing Precautions:

____ Multiple Swallows ____ Alternate Solids/Liquids

____ No Straw

Dysphagia Treatment: ____ Exercises (specify):

____________________________________________________________________________
____ Modalities (specify):
___________________________________________________________________________
Add long and short term goals

________________________________________________________

________________________________________________________

Graduate Clinician

Clinical Supervisor