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UT Erlanger Physicians Group
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Adolescent Medicine
Anesthesiology
Atrial Fibrillation (Afib)
Audiology - Pediatric
Bariatrics
Behavioral Health
Behavioral Science
Cardiac Electrophysiology
Cardiology
Cardiology - Pediatric
Cardiology - Structural
Cardiothoracic Surgery
Cerebrovascular Disease
Colon and Rectal Surgery
Craniofacial Care
Craniofacial Speech Pathology
Craniofacial Surgery
Critical Care
Critical Care - Pediatric
Dental
Dermatology
Developmental Pediatrics
Emergency Medicine
Emergency Medicine - Pediatric
Endocrinology
Endocrinology - Pediatric
Family Medicine
Gastroenterology
Gastroenterology - Pediatric
General Pediatrics
Genetics
Gynecology
Hand and Upper Extremity Surgery
Hematology/Oncology - Adult
Hematology/Oncology - Pediatric
Hospitalist Services and Inpatient Medicine
Hypertension Management
Incontinence, Pelvic Reconstruction
Infectious Diseases
Internal Medicine
Interventional Cardiology
Neonatology
Nephrology and Hypertension
Nephrology and Hypertension - Pediatric
Neurohospitalist
Neurology
Neurology - Pediatric
Neuromuscular Medicine
Neurosurgery
Neurosurgery - Pediatric
Nurse Midwifery
Obesity Medicine
OB-GYN
Occupational Therapy
Oncology
Oncology - Gynecology
Orthopaedic Oncology
Orthopaedic Spine Surgery
Orthopaedic Trauma
Orthopaedics
Orthopaedics - Pediatric
Palliative Care
Pediatric Infectious Diseases
Pediatric Plastic Surgery
Pediatrics
Pharmacy
Physical Medicine and Rehabilitation
Physical Therapy
Plastic Surgery
Preventive Medicine
Primary Care
Psychiatry
Psychiatry - Pediatric
Psychology
Psychology - Pediatric
Pulmonary Medicine
Pulmonary Medicine - Pediatric
Radiation Oncology
Radiology - Diagnostic
Radiology - Interventional
Radiology - Pediatric
Reconstructive Surgery
Respiratory Medicine
Rheumatology
Sleep Medicine
Social Work
Spine Surgery
Sports Cardiology
Sports Medicine
Stroke
Surgery - General
Surgery - Pediatric
Surgery - Vascular
Surgical Critical Care
Thoracic and Cardiac Surgery
Thoracic Surgery
Transplant
Transplant Hepatology
Urogynecology
Urology
Urology - Pediatric
Vascular Interventional Radiology
Vascular Medicine
Vascular Neurology
Women's Health
Wound Care
Zip Code
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15 Miles
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75 Miles
100 Miles
Medical Services
CENTERS OF EXCELLENCE
Bariatrics
Cancer
Heart and Lung
Emergency
Neuroscience
Orthopaedics
Pediatrics
Primary Care
Surgery
Trauma
Urology
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Locations
Baroness Hospital
Baroness Hospital
975 E 3rd St Chattanooga, TN 37403
423-778-7000
Children's Hospital at Erlanger
Children's Hospital at Erlanger
910Blackford St Chattanooga, TN 37403
423-778-6011
Bledsoe Hospital
Bledsoe Hospital
71 Wheelertown Ave. Pikeville, TN 37367-5246
423-447-2112
East Hospital
East Hospital
1751 Gunbarrel Rd. Chattanooga, TN 37421
423-680-8000
Western Carolina Hospital
Western Carolina Hospital
3990 E. US Hwy. 64 Alt. Murphy, NC 28906
828-837-8161
North Hospital
North Hospital
632 Morrison Springs Rd. Chattanooga, TN 37415
423-778-3300
Emergency Rooms
Emergency Rooms
Erlanger Health System staffs 6 Emergency Departments that serve children and adults in the East Tennessee region.
Walk-In Care
Walk-In Medical Care
Imaging Centers
Imaging Centers
Community Health Centers
Community Health Centers
Southside
423-778-2700
Dodson Ave.
423-778-2800
Premier Health
423-648-7770
Erlanger Behavioral Health Hospital
Erlanger Behavioral Health Hospital
804 N. Holtzclaw Ave. Chattanooga, TN 37404
877-384-4375
Erlanger at Volkswagen Drive
Erlanger at VW
7380 Volkswagen Dr. Chattanooga, TN 37416
423-778-8950
Primary Care
Primary Care Practices
Erlanger
Medical Group
Patient & Family
Resources
Billing & Insurance
Food and Dining
Patient Tools & Resources
Healthy U blog
Pay Your Bill Now
Share Your Story
Visitor Information
Western Carolina Patient Portals
Policies
For Healthcare
Professionals
Find a Doctor
Medical Services
Locations
Patient & Family
Resources
For Healthcare
Professionals
Find a Doctor
Find a Provider
UT Erlanger
Physicians Group
Schedule an
Appointment
Select Specialty
Adolescent Medicine
Anesthesiology
Atrial Fibrillation (Afib)
Audiology - Pediatric
Bariatrics
Behavioral Health
Behavioral Science
Cardiac Electrophysiology
Cardiology
Cardiology - Pediatric
Cardiology - Structural
Cardiothoracic Surgery
Cerebrovascular Disease
Colon and Rectal Surgery
Craniofacial Care
Craniofacial Speech Pathology
Craniofacial Surgery
Critical Care
Critical Care - Pediatric
Dental
Dermatology
Developmental Pediatrics
Emergency Medicine
Emergency Medicine - Pediatric
Endocrinology
Endocrinology - Pediatric
Family Medicine
Gastroenterology
Gastroenterology - Pediatric
General Pediatrics
Genetics
Gynecology
Hand and Upper Extremity Surgery
Hematology/Oncology - Adult
Hematology/Oncology - Pediatric
Hospitalist Services and Inpatient Medicine
Hypertension Management
Incontinence, Pelvic Reconstruction
Infectious Diseases
Internal Medicine
Interventional Cardiology
Neonatology
Nephrology and Hypertension
Nephrology and Hypertension - Pediatric
Neurohospitalist
Neurology
Neurology - Pediatric
Neuromuscular Medicine
Neurosurgery
Neurosurgery - Pediatric
Nurse Midwifery
Obesity Medicine
OB-GYN
Occupational Therapy
Oncology
Oncology - Gynecology
Orthopaedic Oncology
Orthopaedic Spine Surgery
Orthopaedic Trauma
Orthopaedics
Orthopaedics - Pediatric
Palliative Care
Pediatric Infectious Diseases
Pediatric Plastic Surgery
Pediatrics
Pharmacy
Physical Medicine and Rehabilitation
Physical Therapy
Plastic Surgery
Preventive Medicine
Primary Care
Psychiatry
Psychiatry - Pediatric
Psychology
Psychology - Pediatric
Pulmonary Medicine
Pulmonary Medicine - Pediatric
Radiation Oncology
Radiology - Diagnostic
Radiology - Interventional
Radiology - Pediatric
Reconstructive Surgery
Respiratory Medicine
Rheumatology
Sleep Medicine
Social Work
Spine Surgery
Sports Cardiology
Sports Medicine
Stroke
Surgery - General
Surgery - Pediatric
Surgery - Vascular
Surgical Critical Care
Thoracic and Cardiac Surgery
Thoracic Surgery
Transplant
Transplant Hepatology
Urogynecology
Urology
Urology - Pediatric
Vascular Interventional Radiology
Vascular Medicine
Vascular Neurology
Women's Health
Wound Care
UT Erlanger Physicians Group
Search Practice Name
Search Practice Type
Select Practice Type
Adolescent Medicine
Anesthesiology
Atrial Fibrillation (Afib)
Audiology - Pediatric
Bariatrics
Behavioral Health
Behavioral Science
Cardiac Electrophysiology
Cardiology
Cardiology - Pediatric
Cardiology - Structural
Cardiothoracic Surgery
Cerebrovascular Disease
Colon and Rectal Surgery
Craniofacial Care
Craniofacial Speech Pathology
Craniofacial Surgery
Critical Care
Critical Care - Pediatric
Dental
Dermatology
Developmental Pediatrics
Emergency Medicine
Emergency Medicine - Pediatric
Endocrinology
Endocrinology - Pediatric
Family Medicine
Gastroenterology
Gastroenterology - Pediatric
General Pediatrics
Genetics
Gynecology
Hand and Upper Extremity Surgery
Hematology/Oncology - Adult
Hematology/Oncology - Pediatric
Hospitalist Services and Inpatient Medicine
Hypertension Management
Incontinence, Pelvic Reconstruction
Infectious Diseases
Internal Medicine
Interventional Cardiology
Neonatology
Nephrology and Hypertension
Nephrology and Hypertension - Pediatric
Neurohospitalist
Neurology
Neurology - Pediatric
Neuromuscular Medicine
Neurosurgery
Neurosurgery - Pediatric
Nurse Midwifery
Obesity Medicine
OB-GYN
Occupational Therapy
Oncology
Oncology - Gynecology
Orthopaedic Oncology
Orthopaedic Spine Surgery
Orthopaedic Trauma
Orthopaedics
Orthopaedics - Pediatric
Palliative Care
Pediatric Infectious Diseases
Pediatric Plastic Surgery
Pediatrics
Pharmacy
Physical Medicine and Rehabilitation
Physical Therapy
Plastic Surgery
Preventive Medicine
Primary Care
Psychiatry
Psychiatry - Pediatric
Psychology
Psychology - Pediatric
Pulmonary Medicine
Pulmonary Medicine - Pediatric
Radiation Oncology
Radiology - Diagnostic
Radiology - Interventional
Radiology - Pediatric
Reconstructive Surgery
Respiratory Medicine
Rheumatology
Sleep Medicine
Social Work
Spine Surgery
Sports Cardiology
Sports Medicine
Stroke
Surgery - General
Surgery - Pediatric
Surgery - Vascular
Surgical Critical Care
Thoracic and Cardiac Surgery
Thoracic Surgery
Transplant
Transplant Hepatology
Urogynecology
Urology
Urology - Pediatric
Vascular Interventional Radiology
Vascular Medicine
Vascular Neurology
Women's Health
Wound Care
Zip Code
Distance
5 Miles
10 Miles
15 Miles
25 Miles
50 Miles
75 Miles
100 Miles
Medical Services
CENTERS OF EXCELLENCE
Bariatrics
Cancer
Heart and Lung
Emergency
Neuroscience
Orthopaedics
Pediatrics
Primary Care
Surgery
Trauma
Urology
Women's
FEATURED SERVICES
Express Care
Innovation and Research
Transplant
See Full List of Services
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
Locations
Baroness Hospital
Baroness Hospital
975 E 3rd St Chattanooga, TN 37403
423-778-7000
Children's Hospital at Erlanger
Children's Hospital at Erlanger
910Blackford St Chattanooga, TN 37403
423-778-6011
Bledsoe Hospital
Bledsoe Hospital
71 Wheelertown Ave. Pikeville, TN 37367-5246
423-447-2112
East Hospital
East Hospital
1751 Gunbarrel Rd. Chattanooga, TN 37421
423-680-8000
Western Carolina Hospital
Western Carolina Hospital
3990 E. US Hwy. 64 Alt. Murphy, NC 28906
828-837-8161
North Hospital
North Hospital
632 Morrison Springs Rd. Chattanooga, TN 37415
423-778-3300
Emergency Rooms
Emergency Rooms
Erlanger Health System staffs 6 Emergency Departments that serve children and adults in the East Tennessee region.
Walk-In Care
Walk-In Medical Care
Imaging Centers
Imaging Centers
Community Health Centers
Community Health Centers
Southside
423-778-2700
Dodson Ave.
423-778-2800
Premier Health
423-648-7770
Erlanger Behavioral Health Hospital
Erlanger Behavioral Health Hospital
804 N. Holtzclaw Ave. Chattanooga, TN 37404
877-384-4375
Erlanger at Volkswagen Drive
Erlanger at VW
7380 Volkswagen Dr. Chattanooga, TN 37416
423-778-8950
Primary Care
Primary Care Practices
Erlanger
Medical Group
Patient & Family
Resources
Billing & Insurance
Food and Dining
Patient Tools & Resources
Healthy U blog
Pay Your Bill Now
Share Your Story
Visitor Information
Western Carolina Patient Portals
Policies
For Healthcare
Professionals
Find a Doctor
Medical Services
Locations
Patient & Family
Resources
For Healthcare
Professionals
About Us
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Careers
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| Swallow Study form
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Case History Form - Modified Barium Swallow Study (MBSS)
This form will provide additional insight for the Speech Pathologist performing the study. Please submit the form before calling to schedule an MBSS.
Patient Name
*
Referring Facility
*
Referring Facility Phone Number
*
Referring Facility Fax Number
*
Date of scheduled MBSS
*
Is the patient under 250lbs?
*
No
Yes
Is the patient under the age of 18?
*
Yes
No
History of present illness
*
Past medical history
*
Indication for MBSS
Dysphagia
CVA
Globus sensation
Odynophagia
Laryngeal abnormalities
Inhalation of food/vomitus
What is the patient's current diet consistency? (choose all that apply)
Solid:
Regular
Mechanical Soft
Ground/chopped meats
Pureed
Liquid:
Regular/thin
Nectar-thick
Honey-thick
Pudding-thick
Non-oral:
PEG
NGT
TPN
Is the patient receiving swallowing therapy?
Yes
No
If YES, please explain
Does the patient utilize any safe swallowing and/or compensatory strategies during meals?
*
Yes
No
If YES, please explain
Has the patient had a recent MBSS?
*
Yes
No
If YES, what were the results?
Your name and title
*
Your Email Address
*