DEVELOPMENTAL SCREENING

Child: [Name]
Date of screening: [Date]
Visit: [Well-child visit, scheduled screen, or visit for a concern]
Clinician: [Name, credentials]

CHILD AND AGE
Date of birth and age: [Date; chronological age in months and days]
Gestational age at birth: [Weeks; term or preterm]
Corrected age: [Chronological age minus the weeks born early, for a child born preterm and under age 2; or not needed]
Informant: [Caregiver and relationship, language used, interpreter if any]

SURVEILLANCE
Family's concerns: [Worries about movement, speech, play, behavior, or learning, in the caregiver's words; or none]
Earlier development: [Past milestones, past screens and results, services already in place]
Risk factors: [Preterm birth, NICU stay, a sibling or relative with autism or delay, hearing problems, exposures, family stress]
Loss of skills: [Any words, social, or motor skills lost, and when; or none]

MILESTONES BY DOMAIN
Gross motor: [Skills seen and reported]
Fine motor: [Skills seen and reported]
Language and communication: [Sounds or words, understanding, gestures and pointing, response to name]
Problem solving: [How the child explores and plays with objects; pretend play]
Personal-social: [Eye contact, shared enjoyment, imitation, self-help]
Seen in clinic: [What you observed yourself during the visit]

STANDARDIZED SCREENING
General screen: [Tool and age form, such as ASQ-3 or PEDS; who completed it; scores by domain against the cutoffs]
Autism screen: [Tool such as M-CHAT-R/F; total score and risk band; Follow-Up Interview score; or not due]
Other screens: [Social-emotional, language, or other tools, with results; or none]

HEARING AND VISION
Hearing: [Newborn screen result, risk factors, audiology since, response to sound today]
Vision: [Red reflex, fixing and following, eye alignment, or instrument-based screen]

EXAMINATION
Growth: [Weight, length or height, head circumference with percentile and trend; plotted for corrected age if preterm]
Neurological: [Tone, strength, symmetry, reflexes, gait]
Other findings: [Skin findings, dysmorphic features, or other relevant signs; or none]

RESULT
Overall: [On track, monitor with an earlier rescreen, or refer]
Reasons: [The screen results, surveillance, and risk factors behind the decision]
Red flags: [Any found, with detail; or none]

PLAN
Rescreen: [Tool, age form, and date]
Referrals: [Early intervention, audiology, speech-language pathology, developmental pediatrics, or other; date sent]
Consent to share: [What the family agreed can be sent, and to whom]
Explained to the family: [What the result means, what happens next, ideas for home, their questions]
Follow-up: [Next visit, and reasons to come back sooner]

Signed: [Clinician name, credentials, date and time]