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Home
About FEES
Services
Resources
Advocacy
Education & Information
Contact Us
For Patients
For Facilities/Providers
Patient Form
Name
(Required)
First
Last
Date
(Required)
MM slash DD slash YYYY
Email
Phone #
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Have you ever been treated by an SLP before?
(Required)
Yes
No
If yes, were you treated for swallowing problems?
Yes
No
Check if you have experienced any of the following:
Stroke
ACDF procedure
Dementia
Cleft lip and palate
Achalasia
Thrush, and/or trauma to the head and neck regions.
Head and neck cancer
Brain tumor
Recent intubation
COPD
Recent stay in the ICU >3 days
Parkinson's disease
Neurodegenerative disease
Head and neck cancer
Esophageal dilation
Check any of the following symptoms you experience:
Feeling of something stuck in your throat
Painful or difficulty swallowing
Coughing or throat clearing while eating and drinking
Difficulty chewing
Recurrent pneumonia
Unexplained weight loss
Change in vocal quality, and/or modifying the way your eat or drink
Have you ever had a MBSS/VFSS or FEES completed?
Yes
No
Are you actively participating in dysphagia therapy?
Yes
No
Check your current living situation:
Independent at home
Living with caregiver
SNF
ALF/ILF
Hospital
Rehab Center
Do you have a script for an instrumental evaluation of swallowing from your physician?
Yes
No
