SLT Consultation Request
Geriatric Medicine Unit
Your Referral Matters.
Please take a moment to complete this form. Your input plays a crucial role in ensuring high-quality and coordinated care for our patients.
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Type of Request?
*
Swallowing Assessment
Language & Speech Assessment
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Name of the Doctor In-Charge and Contact Number?
*
Unit
*
Please Select
A1
A2
B1
B2
C1
C2
D1
D2
E1
E2
Nephrology
Other
Name of the Patient
*
Location
*
Please Select
B6
B7
E7
F7
G7
H7
W20
W21
W22
W27
ECU-1
ECU-2
CCU
Room Number
*
Caregiver Phone Number
*
Medical Diagnosis and Date of Onset
*
Reason for the Referral
*
Primary Language Spoken
*
Arabic
Other
Hearing Status
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Good
Affected
Deaf
Vision Status
*
Good
Affected
Blind
Currently, Does the Patient Complain of any Pain? If Yes, What Kind of Pain Does He/She Have?
*
No
Other
Allergies, If Yes, Please Mention the Type of Allergies ...
*
No
Other
Is the Patient on Tracheostomy?
*
No
Yes
Is the Patient on a Ventilator?
*
No
Yes
Is the Patient Able to Sit 60 to 90 Degree Position?
*
No
Yes
Oral Hygiene ...
*
Good
Poor
Is the Patient NPO (nothing by mouth)?
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No
Yes
Is the Patient Using an Alternative Feeding Method? If Yes, Please Mention the Method and the Date Placed ...
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No
Other
Symptoms Reported by the Patient or the Family (Check all that Apply):
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Coughing
Choking
Drooling
Pain on swallowing
Weight loss
Hx of aspiration pneumonia
Difficulty swallowing foods
Difficulty swallowing liquids
Difficulty swallowing pills
Start of Swallowing Problem
*
Gradual
Sudden
Past few weeks
Past few months
6-12 months
Hx of Aspiration Pneumonia? If Yes, Please Mention the Date
*
No
Other
Previous Swallowing Evaluation?
*
No
Yes
Neurological Deficits?
*
Yes
No
Heart Disorders?
*
Yes
No
Lung/Breathing Disorders?
*
Yes
No
Head/Neck Cancer? If Yes, Please Write the (1) Location, (2) Type, and (3) Date of the Diagnosis:
*
No
Other
Mental Status (Check all that Apply):
*
Alert
Confused
Responsive
Lethargic
Cooperative
Uncooperative
Impulsive
Combative
Unresponsive
Any Extra Information Would You Like to Mention?
Please Send Referral to Geriatric Medicine Unit
*
Yes
Please Upload a Picture of the Consultation Request in the HIS ...
*
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