Dysphagia Case History Form -

Dysphagia Case History Form

Dysphagia Case History Form -KENT

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Child's name

Date of birth

Gender

Child's NHS number

Address

Home language

Parent / carer telephone number

Parent / carer email address

Details of people living at home

Main concerns

What are your hopes and expectations from the Dysphagia Assessment and/or Therapy?

Professionals involved

Paediatrician

Speech and Language Therapist

ENT

Occupational Therapist

Physiotherapist

Medical Specialist

None of the above

General Health/Milestones

Were there any complications with the pregnancy or birth?

If yes, please give details

At approximately what age did your child achieve the following milestones?

Sit

Crawl

Walk independently

Run

Say first word

Feed self

Does your child have a medical diagnosis?

If yes, please give details

Do you have concerns regarding your child’s hearing?

Has your child had a history of:

Ear infections

Frequent colds

Seizures

Allergies

Other

Please give details and approximate dates of any illnesses, hospitalisations or serious accidents

Is your child on any medication? If yes please specify

Eating and drinking needs

Is there a history of reflux, e.g. vomiting, associated with feeding? If yes please give full details

How did you feed your child as a baby; breast, formula, or combination? If you breast fed, did your child have any difficulties with latching?

Does your child experience coughing/choking during feeding? If so at what stage does this occur, e.g. beginning, middle, end of/ following feed/meal?

Does your child have an alternative means of feeding in place (i.e. NG tube, gastrostomy etc.) or is there a history of this? If yes please give full details

Has there been a history of recent weight loss? Is there a history of poor weight gain or failure to thrive?

Current weight

Centile if known

Current length/height

Is feeding a positive experience e.g. is your child settled during feeding or after? Is there excessive crying? If yes please give full details. Does your child present with a change of movements/facial expressions/vocalisations during mealtime (e.g. back arching, grimacing, blinking/eye widening, wet vocalisations). If yes please give full details. When does this occur? Beginning, during or following feed/meal?

How much fluid is your child accepting at the current time?

How much solid food is your child accepting (spoonful)? Please include types and texture of food taken e.g. puree, mashed, chopped.

How long does a mealtime take? (minutes)

What position do you feed your child in?

Describe your child's transitions with food, e.g. 4-6 months began to eat mash; 6 months began to be introduced to lumpy solids, manages soft chew; 8 months can cope with harder lumps and feed from spoon without spilling; 4-11 months began to self-feed etc.

Please provide any other information that you feel is vital to understand

Consent

I agree for my child to be seen for an assessment and/or therapy run by The Children's Wellness Centre's Dysphagia trained Speech and Language team. I understand I can withdraw my consent at any time.

I agree for any relevant information about my child to be shared between relevant professionals (e.g. school, doctor, psychologist, NHS therapist etc) in confidence, in the best interest of the child’s development.

I am aware that session notes will be owned and stored by my child's individual therapist

I understand that audio, video or photographic records may be made as part of my child’s assessment and therapy

I agree to the use of electronic communication. All documents will be password protected and saved as a PDF

Terms and Conditions of Therapeutic Services within The Children’s Wellness Centre.

By ticking this box, the client is accepting the terms and conditions below:

Our Therapists will adopt a client-led approach and will offer advice, support and options for next steps, but it is the client’s responsibility to decide what is right for their child

The Therapist that you are seeing is DBS checked and holds Professional Indemnity insurance, practicing within the framework of their profession and registrations

The Therapist reserves the right not to accept a referral, terminate an assessment or not to circulate an assessment report if the referral appears to be outside their area of expertise or the client fails to comply with the terms and conditions set out in this agreement

Any information shared by the client with the Therapist and The Children's Wellness Centre is treated as confidential, unless a safeguarding concern is disclosed. Client details will not be passed onto other parties unless specifically requested e.g. forwarding reports to other professionals and schools

Payment for a Dysphagia Assessment is required at the time of booking, in order to secure the space. Payment for weekly Therapy sessions is due prior to each session

Payment is usually made via BACS and clients will receive an email invoice once they have booked. Your Assessment is confirmed on receipt of payment

Please note we have a 48-hour cancellation policy. Late cancellations (not within 48-hours) and missed appointments, will still need to be charged in full

For any clients claiming through their health insurance, payment must be settled directly with The Children’s Wellness Centre by the client and can be reclaimed via their insurance provider, using the receipt we can provide

If the client has a complaint against the Therapist that they are seeing, they must inform The Children’s Wellness Centre, emailing jake@childrenswellnesscentre.co.uk immediately and all efforts will be made to resolve and settle any disputes, without litigation