Case history for Patients presenting with COPD and (possible) Dyspahgia
feel free to print and keep for you personal records*(Adapted from the questionnaire used in the John Hopkins Swallowing Centre, found in, Castell D.O., and Donner M.W., 1987)
1. Basic Information:
Name:
Age:
2. Work/Personal History
Profession
Exposure to dust, chemicals
Smoker
For how long
When/have they quit
3. Previous Medical examinations
Neurological
ENT/GI
Radiology
Swallowing examination, including VFS
Most recent hospital stay
For how long
4. Family history
General
Developmental
Swallowing
5. Food History
Cultural identity (could include: religion and/or ethnicity):
Foods avoided pre-morbidity
Post-morbidity
Preferred pre-morbidity
Post-morbidity
Depend on others for:
food preparation
feeding
Are preferred foods given
Who is the primary food provider
Gauge feelings towards this person
What utensils are used (i.e., eat with hands or adapted devices)
What do you eat for:
Breakfast
Lunch
Dinner
Snacks/treats
Taking any supplements (i.e., Ensure)
Preferred textures:
Food
Liquids
Meal time environement
Where do you generally eat
With whom
If at a restaurant/noisier environment, are symptoms more severe?
6. Eating habits:
Slow-average-fast (pre and post swallowing difficulty)
What state (i.e, sleepy, angry, sad, agitated) does Pt. Often feel at mealtimes?
(note this in mealtime observation also. Could also inquire with caregivers)
Manoeuvres (posture, head/neck position)
Tastes
Food temperatures
Carbonated beverages
Loss of food from front of mouth
Fatigue during meals
More fatigue after swallows
General duration of meals
Cough during meals
Choking during meals
How many episodes
Where: at home? When out?
Loss of appetite/food refusal
Afraid to initiate swallow
Pain during swallow
7. Swallowing History:
Duration of swallowing trouble
When did it begin?
Progressive or intermittent
Are solids or liquids harder to swallow
Foods causing symptoms
Liquids: i.e., water, milk, orange juice
Pureed Food: i.e., mashed potatoes, milk shakes, ground beef
Solid Foods: met, chicken, fish and nuts
8. Voice Changes
When began
Comprehensible
Nasality
Hoarseness/breathiness/gurgly
Was it first symptom prior to swallowing difficulties
9. Sleep
Sudden onset of snoring
Sleep apnea
Change in sleeping position

10. Oesophageal symptoms (including reflux)
Heart burn
Sour taste in mouth
Sore throat
Lump in throat
Wet pillow in morning
Food sticking in throat (neck, chest); try to pinpoint site of most difficulty
Does heart rhythm change during swallow
11. Chest pain
12. Respiratory Symptoms
Chronic cough
Pneumonia in past (how many episodes)
Medications for this
Exasperations of COPD
How often
Most recent episode (and previous)
Postnasal drip

13. Current medical conditions
14. Medications/Supplements taken (including addition Oxygen)
15. General medical history
Childhood diseases/developmental disorder/foreign body ingestion
Major illnesses
Previous surgery
Trauma
Has Pt. Ever had NG or PEG feeding
Weigh loss
How much
Since when
Neurological history
Gait
Weakness
Reference

Castell, D. and M. Donner (1987). "Evaluation of dysphagia: A careful history is crucial." Dysphagia 2 (2): 65-71.