April 16, 2010

問卷內容

吞嚥困難問卷調查

填卷人:________________

1.老人的年齡:________

2.老人的性別:

3.老人吞嚥困難的狀況? __________________________________

從何時開始? ________________________________

4.是否有吞嚥困難疾病? □ 否

服用藥物? __________________________________

5.是否有其他疾病?  

疾病名稱: ___________________

服用藥物? __________________________________

6.是否需要有工具輔導吞嚥?

工具是? ____________________________________

7.吞嚥之飲食? ___________________________________________

                         ___________________________________________

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