First Name
*
Last Name
Email Address
*
Noticed changes with your swallow or communication functioning?
*
Yes
No
Someone I know has
Other (please specify in comments section)
Have you had a stroke, traumatic brain injury or any trauma that has had an impact on your swallowing or communication?
*
Yes
No
Someone I know has
Other (please specify in comments section)
Have you been diagnosed with a neurological, degenerative or other condition that has impacted your swallow or communication?
*
Yes
No
Someone I know has
Other (please specify in comments section)
Have you had any medical treatment and/or surgical intervention that has resulted in swallow or communication issues?
*
Yes
No
Someone I know has
Other (please specify in comments section)
Noticed changes to your voice and/or speech?
*
Yes
No
Sometimes
Someone I know has
Other (please specify in comments section)
Have you had any coughing and/or choking when eating or drinking?
*
Yes
No
Sometimes
Someone I know has
Other (please specify in comments section)
Noticed changes to your language (e.g. word finding, attention, processing/understanding information, confusion, communication fatigue)
*
Yes
No
Sometimes
Someone I know has
Other (please specify in comments section)
Have you commenced medication(s) that may have resulted in a change to your swallow, saliva management or communication?
*
Yes
No
Someone I know has
Other (please specify in comments section)
Do you have a respiratory condition that impacts your eating and/or drinking?
*
Yes
No
Sometimes
Someone I know has
Other (please specify in comments section)
Have you experienced any unintentional weight loss?
*
Yes
No
Unsure
Someone I know has
Other (please specify in comments section)
Do you find yourself avoiding social events or being in public due to changes with your swallow or communication?
*
Yes
No
Sometimes
Someone I know does
Other (please specify in comments section)
Do you have a Tracheostomy or have had a Laryngectomy and need support managing at home?
*
Yes
No
Sometimes
Someone I know does
Other (please specify in comments section)
Other comments or concerns
Please wait, files are uploading..
Submit
