LETTER FOR YOUR DOCTOR
(1) Click here to print this letter.
(2) Fill it out.
(3) Get it to the primary medical provider.
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
(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)
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
I look forward to hearing from you at your earliest convenience.
You can reach me in the following ways:
Home Phone ( )__________________________
Cell phone ( )__________________________
Fax ( )__________________________
Mailing Address _____________________________________________
Thank you very much for your attention and concern.
Your name printed