LETTER FOR YOUR DOCTOR

(1) Click here to print this letter.
(2) Fill it out.
(3) Get it to the primary medical provider.

Date_____________

Dear Doctor___________________________________________

I am concerned about swallowing in

______________________________________________________
Name of Person

______________
Date of Birth

She/He is my:        mother        father        wife        husband        other ______________

I have noticed these problems over the past
__________   weeks/months:

(Circle those that apply)

difficulty swallowing        coughing        choking        gagging

wheezing        teary eyes       runny nose         chest pain

nasal regurgitation     weight loss       recurrent fevers      hurts to swallow    sore throat

refuses food   drooling   voice change:  hoarse   weak  gurgly

         nasal      frequent throat-clearing       tired out by eating         nausea

loss of taste or smell   bites toungue   burps frequently

food feels stuck/won’t go down      food sticks to throat

difficulty with:  juice  meat  pills  other___________________

  embarrassed to eat in public    favorite foods   eats very slowly   tired out by eating

struggles to eat   eats rapidly   dehydration     sore gums   loose dentures

bad breath     recent fall   gets dizzy with swallowing     other observations

     __________________________________________________
______________________________________________

She/He has these medical problems:
___________________________________________________________
___________________________________________________________
___________________________________________________________

Her/His last hospitalization was ______________ (date)

at ___________________________________(hospital)

for these reasons: ____________________________________________

___________________________________________________________

She/He is taking the following medications (prescribed and over-the-counter):
___________________________________________________________
___________________________________________________________
___________________________________________________________

I am most concerned about:

choking       aspiration       pneumonia

nutrition            hydration          difficulty swallowing pills

Other_____________________________________________________
___________________________________________________________

I look forward to hearing from you at your earliest convenience.

You can reach me in the following ways:

Home Phone  (       )__________________________
Cell phone     (       )__________________________
Fax                 (       )__________________________
E-mail _____________________________________
Mailing Address _____________________________________________
___________________________________________________________

Thank you very much for your attention and concern.

Sincerely,

_____________________________
Your signature

_____________________________
Your name printed

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