Data Selection Form
1. Date of admission to rehabilitation clinic between 1 Jan 2006 and 31 Dec 2006?
2. Stroke victim?
A. Patient Details:
1. Age of Stroke Victim: __________
2. Date of Stroke:___________
3. Date of Admission to Rehabilitation Clinic:___________
4. Date of Discharge form Rehabilitation Clinic (If Applicable):____________
B. Gender:
Male 
Female 
C. Relevant Case History Facts:
___________________________________________________________________
D. Overall Physical Functioning Post-Stroke:
a. Good
O
b. Average
O
c. Poor
O
E. Injuries and Operations:
a. Confirmed brain injury (CT scan)
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b. Cranial complications (e.g. CSF leak, infection)
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c. Associated injuries (e.g. fracture (s))
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d. Cranial operations
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e. Non- cranial operations
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f. None
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g. Other:
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_____________________________________________________________
E. Medication:
a. Before Stroke:______________________________________________
b. After Stroke:________________________________________________
F. Severity(1) & Type(2) of Stroke:
1.
a. Mild
b. Moderate
c. Severe
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2.
a.
b.
c.
d.
Cerebral
Cerebellar
Brainstem
Global
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2
G. Dysphagia Incidence and Identification:
1. Post- stroke dysphagia:
Yes
No
O
O
2. Diagnostic assessment method:
a. Bedside evaluation
O
b. Clinical swallowing assessment
O
c. Observation during and / or after eating
O
d. Videofluoroscopic modified barium swallow
O
e. Videofluoroscopic swallowing study
O
f. Other: ___________________________________________
3. Dysphagia diagnostic details:
a. Oral preparatory phase problems
b. Oral phase problems
c. Pharyngeal phase problems
d. Oesophageal phase problems
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4. Dysphagia Severity & Feeding:
a. Able to feed self independently
O
b. Diet
i. Oral
ii. Non-oral
O
O
c. Stage of Diet:
i. ___________
* I.e. PEG, NGT, Stage 1, 2, 3 or 4; 4 meaning full ward diet.
d. Functional Independence & Assessment Measure (FIM/FAM) score
(If Applicable):
______ (1 – 7).
5. Oral Sensory Motor Evaluation (OSME):
i. Normal Structures
ii. Normal Functioning
iii. Abnormalities
Specific:
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O
_____
_____
___________
iv. Other:
H. Dysphagia Management:
1. Did the patient receive treatment for dysphagia?
Yes
No
2. Management techniques used in the rehabilitation clinic:
a. Speech therapy:
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3
i. Monitoring swallowing
ii. Dietary modifications (changing food consistency)
iii. Swallowing techniques
O
O
O
b. Dietician:
i. Dietary modifications (change food consistency)
ii. Nutritional modifications
iii. Counseling

O
O
c. Short-term nasogastric feeding tube (NGT)
O
d. PEG tube feeding
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e. Other _________________________________________________
3. Number of times dysphagia treatment(s) was/were received:
v. Every day
O
vi. Other: _________________
I.
Fatality: Incidence and Cause:
1. Did morbidity occur?
Yes
No
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2. Was the cause of morbidity related to the patient’s dysphagia?
Yes

No
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3. Cause of dysphagia-related morbidity:
e. Aspiration Pneumonia

f. Pneumonia
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g. Aspiration
`
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h. Malnutrition
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i. Dehydration
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j. Asphyxia
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k. Lung infection
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l. Complications due to PEG tube insertion
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m. Other ______________________________________________
L. Personality/ Behaviour Disturbances Post-Stroke:
a) Changes in general
b) Depression
c) Lack motivation
d) Impulsivity
e) Aggression
f) Loss of temper/ short temper
g) Memory loss for accident
h) Irritability
i) Appetite disturbances
j) Sleep disturbances
k) Lack of insight
l) Lack of confidence
m) Inattention/ reduced alertness
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4
n)
o)
p)
q)
r)
s)
t)
u)
Anxiety
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Emotional withdrawal/ blunted affect
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Disinhibition
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Guilt feelings

Frustration/ agitation

Social isolation

No disturbances
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Other:
____________________
N. Cognition Post-stroke:
a) Orientation
b) Attention/ concentration
c) Motor speed
d) Constructional
e) Memory
a. Incidental memory
b. Verbal learning/ short-term memory
f) Executive function
g) Higher Order Language
i.
Perceive the main point
ii.
Inferential skill
iii.
Reasoning and problem solving
iv.
Planning
O
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