Feeding and Swallowing Assessment

Feeding and Swallowing Assessment

REFERRAL FORM

Referrals will only be accepted with a signature from the child’s GP or Consultant.

Parental consent is also needed

Child's Details

Name: / D.O.B.
Address:
Tel:
Parents'/Carers' Names

Professional Involvement

Name / Address / Tel No.
G.P/Consultant
Health Visitor
Dietitian
Other

Medical Diagnosis

(E.g. Cerebral Palsy, Downs Syndrome, Developmental Delay)

Birth History

Gestational age / Apgar
Birth weight / Centile

Feeding

Breast / Nasogastric tube
Bottle / Orogastric tube
Spoon foods / Finger Foods

Investigations

Has the child had or been referred for any relevant investigations?

Videofluoroscopy / pH study,
Barium meal / Endoscopy

Current Nutrition

Weight: / Centile:
Supplements:

Relevant Medical Information

Does the child suffer from any of the following?

Allergies / Failure to Thrive
Constipation / Dehydration
Gastroeosophageal Reflux / Choking
Aspiration / Motor delay/dysfunction
Respiratory Problems / Cardiac Problems

Medication

Please list below the medication the child is on (please include Thick and Easy if relevant)

Reason for Referral

What are your concerns about the child’s feeding? (Tick as many as appropriate)

Newborn – 6 months

Medical Diagnosis / Preterm
Respiratory difficulties / Cardiac problems
Vomiting / Discomfort around feeding
Prolonged feeds / Oro-facial abnormalities
Growth faltering / Stressful feeding times
Only feeds when asleep / Poor appetite/taking small volumes
Tube fed / Coughing and choking
Makes strange sounds when feeding / Recurrent chest infections

6 – 12 months

Medical Diagnosis / Developmental delay
Refusal to eat / Poor appetite
High parental anxiety / Delayed weaning
Picky eater/limited diet / Recurrent chest infections

12 months +

Not chewing / Still on pureed food
Early medical intervention / Coughing and choking
Growth faltering / Gagging and vomiting
Mealtime battles/anxiety / Sensory issues (won’t touch food)
Overstuffing mouth / Poor appetite

Other Relevant Information

Referral Procedure

The Speech and Language Therapist will automatically refer the child to other members of the feeding team as indicated by the information provided and/or the assessment.

Paediatrician / Physiotherapist
Occupational Therapist / Dietitian

This form will be photocopied and act as a referral to the relevant professionals. The referring agent and GP will be contacted.

Referral Completed by:

Name______Designation:______

Contact address:

Telephone Number:

Consent

Doctor’s signature______Doctor’s name (PRINT)______

Parents consent received yes/no

PLEASE POST TO:

Speech and Language Therapy Department

Timperley Health Centre

169 Grove Lane

Timperley

Altrincham

Cheshire

WA16 6PH