Appendix 1

Checklist for Identifying Possible Eating,

Drinking and /or Swallowing
Difficulties

Client Name:

Date of Birth:

Name of person completing checklist:

Relationship to Client:

Date Completed:

Contact Telephone Number:

Please make sure the client is involved in completing this checklist in accordance
with their ability and wishes

This is not an assessment or a risk assessment but is intended to help you identify the
need to contact a Speech and Language Therapist.

The checklist should take no longer than 10 minutes to complete.

This checklist should be completed by someone who knows the
above person well and who is familiar with how the person eats and drinks.

Please read the instructions carefully at the top of each section and
contact the Speech and Language Therapy Department if you need
further help.

Northumberland, Tyne and Wear NHS Foundation Trust 1

Appendix 1 - Checklist for Identifying Possible Eating, Drinking and /or Swallowing Difficulties
Part o fDP-PGN-01 – SALT – Learning Disability Directorate (NTW(C)26 – Dysphagia Policy)
 Speech and Language Therapy Department

- Insert address -

PLEASE NOTE:
In the event of the person choking, it is presumed that first aid
policies / procedures will be followed as necessary.

Northumberland, Tyne and Wear NHS Foundation Trust 2

Appendix 1 - Checklist for Identifying Possible Eating, Drinking and /or Swallowing Difficulties
Part o fDP-PGN-01 – SALT – Learning Disability Directorate (NTW(C)26 – Dysphagia Policy)
 Checklist for identifying possible eating, drinking and / or swallowing difficulties

Client DOB:

Section 1: Please read statements 1 – 17 below and tick the box where appropriate to
represent the individual named on the front page
If you tick a shaded box, please contact the Speech and Language Therapy Department for advice .

Occasionally

Don’t know
Every Day
No Description

Never
1 He / She coughs or splutters during or after eating or drinking

2 His / Her breathing sounds different (e.g. ‘rattly’) after eating or drinking

3 His / Her voice sounds different (e.g. ‘wet’ or ‘gurgly’) after eating or
drinking

4 His / Her eyes water during or after eating or drinking

5 He / She appears distressed during or after eating or drinking

6 He / She gags, regurgitates or vomits during or after eating or drinking

7 His / Her skin colour changes during or after eating or drinking

8 He / She has clammy skin during or after eating or drinking

9 He / She drools

10 He / She needs to swallow more than once to clear each mouthful

11 He / She looks like he/she struggles to swallow

12 He / She loses food or drink from the mouth or nose whilst eating or
drinking

13 He / She has difficulties with particular foods or textures (e.g. meat,

bread, dry foods etc)

14 He / She has difficulty chewing

15 He / She holds food or drink in the mouth for a long time before
swallowing

16 He / She appears hungry or dehydrated

17 He / She is unwilling to eat or drink

18 He/She eats quickly or overfills his/her mouth

Northumberland, Tyne and Wear NHS Foundation Trust 3

Appendix 1 - Checklist for Identifying Possible Eating, Drinking and /or Swallowing Difficulties
Part o fDP-PGN-01 – SALT – Learning Disability Directorate (NTW(C)26 – Dysphagia Policy)
Client DOB:

Section 2: Please read statements 19 – 23 below and tick the box where appropriate to
show how often it happens
If you tick a shaded box, please contact the Speech and Language Therapy Department for advice.

No: Description No Yes

19 Do his/her mealtimes take longer than in the past?

20 Does the person have recurrent chest infections, suspected

chest infections or is prescribed many regular courses of
antibiotics?
Does the person appear to be anxious leading up to, during or
21
after a mealtime?

22 Are staff anxious about assisting the person at mealtimes?

23 Has he/she experienced a choking episode?

If so, please specify date(s)

Please outline in the space below any other concerns, relevant past history or recent changes regarding
the person’s eating, drinking or swallowing.

Referral to Other Professionals

24 If the person has unintentionally lost weight
Complete nutritional screening tool if available. Monitor weight and food/fluid
intake & contact GP if concern persists
25 If the person experiences difficulties using cutlery / cups etc
Action – Please contact Occupational Therapy
26 If there are concerns about the person’s positioning whilst eating or drinking
Action – Please contact Physiotherapy
27 If there is a change in the person’s general behaviour outside of mealtimes
Action – Please contact Psychology or Psychiatry
28 If there is a noticeable change in the person’s eating, drinking or swallowing since a
change in medication
Action – Please inform the prescribing professional who has made this change
29 If the person is totally refusing food and / or drink
Action – Please contact the GP to ensure adequate hydration and nutrition
If a referral to Speech and Language Therapy is advised, then a referral form …..specify team … should
be completed and sent to the following address:

Speech and Language Therapy Department

Address to be inserted

Northumberland, Tyne and Wear NHS Foundation Trust 4

Appendix 1 - Checklist for Identifying Possible Eating, Drinking and /or Swallowing Difficulties
Part o fDP-PGN-01 – SALT – Learning Disability Directorate (NTW(C)26 – Dysphagia Policy)