吞咽客观评估量表

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1、玉林市第一人民医院康复医学科客观吞咽评估表姓名：      年龄： 性别： 床号：  科室：  住院号：    联系电话： 临床诊断：                 影像学诊断：                   发病日期：   此评估为配合下列某项检查而准备： 1吞咽造影检查(MBSS)2纤维电子喉镜吞咽评估(FEES)  主观资料(S)：诊断/主要病史和体格检查概况____________________________________________________ 既往的言语语言病理治疗_______________________________

2、____________              疼痛报告____________________________________________________                    既往疾病史：□慢性阻塞性肺病，肺气肿，哮喘或其它呼吸道问题　□胃食管反流性疾病□哽噎感□短暂性缺血发作，脑血管意外□其它神经学疾病___________________□认知障碍□手术史________________________□化疗/放疗□吸入性肺炎史/误吸       □气管套管存在或其它影响吞咽的情况□其它 病人的主诉：______________

3、__________________________________目前影响吞咽功能的药物使用情况_______________________________________□N/A 症状的发生:□突然    □逐渐：开始___________接着___________ 症状：□进食固体差□进食液体差   □疲劳时差        □口腔期出现症状□导致体重减轻    □其它________________________                          客观资料（O）:一、进食不同性状食物时造影检查所见：口腔期：  稀流质浓流质糊状食物（

4、布丁）固体食物1.唇闭锁食物摄入                                        2.咀嚼             3.食物从口腔内漏出唇外（量）                                            4.口腔食物残留（量）                                        5.向舌根部的移送                                        6.向咽部的移送                                        7.其

5、它（描述）     咽部期： 喉渗漏误吸隐性/显性残留(+/-)稀流质：勺子一口量用吸管吸连续进食其它                                                                                                                                                                                                                                浓流质：勺子一口

6、量用吸管吸连续进食其它                                                                                                                                                                                                                                糊状食物（布丁）1/2汤匙1汤匙其它                              

7、                                                                                                          固体食物软食硬食                                                                                            混合液体/固体（特定）                                            其它                    

8、