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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?  *Is the patient under the age of 18?  *History of present illness  *Past medical history  *Indication for MBSS 

What is the patient's current diet consistency? (choose all that apply) Solid: 


Non-oral: Is the patient receiving swallowing therapy? If YES, please explain Does the patient utilize any safe swallowing and/or compensatory strategies during meals?  *If YES, please explain Has the patient had a recent MBSS?  *If YES, what were the results? Your name and title  *Your Email Address  *