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Dysphagia History Form Mobile App

Dysphagia History Form mobile app is a for describing the history, history of problem, of a patients dysphagia. The dysphagia history form will want the user to describe problems like swallowing disorders, swallowing difficulties, swallowing problems, severe dysphagia, ect. The question needs for the customer to describe issues and it will want to know the history on how the disorder started. This is a great app for some who does practice in speech-language pathologists, dysphagia screening, oropharyngeal dysphagia, or esophageal dysphagia.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Dysphagia History Form Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Name:

  • Ico integer

    Age:

  • Ico date

    DOB:

  • Ico textbox

    Address:

  • Ico multiline

    City/Zip code:

  • Ico dropdown

    Gender:

  • Ico textbox

    Height:

  • Ico textbox

    Weight:

  • Ico date

    Today’s Date:

  • Ico textbox

    Referral by:

  • Ico textbox

    SS#:

  • Ico textbox

    Contact phone:

  • Ico textbox

    Email address:

  • Ico multiline

    Briefly describe the swallowing or eating problem.

  • Ico multiline

    How long has this problem persisted?

  • Ico multiline

    Who first noticed this problem?

  • Ico dropdown

    The swallowing/eating problem began:

  • Ico dropdown

    The problem is getting:

  • Ico multiline

    How does the swallowing problem affect your life?

  • Ico multiline

    What previous treatments have you tried for this problem?

  • Ico dropdown

    Do you have a feeding tube?

  • Ico multiline

    Have you had swallowing treatment from a speech-language pathologist previously?

  • Ico multiline

    Have you had a modified barium swallow test or a flexible endoscopic evaluation of swallow?

  • Ico dropdown

    Which of the following symptoms apply?

  • Ico textbox

    Other

  • Ico dropdown

    For infants/children only:

  • Ico textbox

    What Type

  • Ico dropdown

    Select

  • ...and More!

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