# Developmental Screening Summary Form

| Form ID | FRM-SCR-001 | Revision | 1.0 |
|---------|-------------|----------|-----|

---

## Section 1: Child Information

| Field | Entry |
|-------|-------|
| Child Name | |
| Date of Birth | |
| Age at Screening | |
| Medical Record Number | |
| Screening Date | |
| Screened By | |

## Section 2: Parent/Guardian Information

| Field | Entry |
|-------|-------|
| Parent/Guardian Name | |
| Relationship to Child | |
| Contact Phone | |
| Email | |

## Section 3: Screening Tool(s) Administered

### Primary Screening Tool
- [ ] ASQ-3 (Ages & Stages Questionnaires, 3rd Edition)
- [ ] M-CHAT-R/F (Modified Checklist for Autism in Toddlers, Revised with Follow-Up)
- [ ] PEDS (Parents' Evaluation of Developmental Status)
- [ ] SWYC (Survey of Wellbeing of Young Children)
- [ ] BRIGANCE Early Childhood Screens
- [ ] Other: _______________

### Screening Tool Version/Age Range
| Tool | Version | Age Range |
|------|---------|-----------|
| | | |

## Section 4: ASQ-3 Results (if applicable)

| Domain | Raw Score | Cutoff Score | Status |
|--------|-----------|--------------|--------|
| Communication | | | ☐ Above ☐ Monitoring ☐ Referral |
| Gross Motor | | | ☐ Above ☐ Monitoring ☐ Referral |
| Fine Motor | | | ☐ Above ☐ Monitoring ☐ Referral |
| Problem Solving | | | ☐ Above ☐ Monitoring ☐ Referral |
| Personal-Social | | | ☐ Above ☐ Monitoring ☐ Referral |

### Overall Concerns Section Results
- [ ] No concerns indicated
- [ ] Concerns noted: _______________

## Section 5: M-CHAT-R/F Results (if applicable)

### M-CHAT-R Initial Screening
- Total Risk Items: _____ / 20
- Critical Items: _____ / 6

### Initial Risk Level
- [ ] Low Risk (0-2 total)
- [ ] Medium Risk (3-7 total)
- [ ] High Risk (8-20 total)

### Follow-Up Interview Conducted
- [ ] Yes
- [ ] No (not indicated)
- [ ] Declined by family

### Follow-Up Results (if conducted)
- Final Score after Follow-Up: _____
- [ ] Passed screening
- [ ] Failed screening - referral recommended

## Section 6: PEDS Results (if applicable)

### Concerns Identified
- [ ] No concerns
- [ ] Predictive concerns (Path A)
- [ ] Non-predictive concerns (Path B)
- [ ] Low concerns (Path C)
- [ ] No concerns but parent comment/question (Path D)
- [ ] No concerns, no questions (Path E)

### Recommended Path
- [ ] Path A: Refer for diagnostic assessment
- [ ] Path B: Screen further with developmental screening tool
- [ ] Path C: Age-appropriate anticipatory guidance
- [ ] Path D: Address specific question/concern
- [ ] Path E: Continue routine surveillance

## Section 7: Developmental Domains Assessed

| Domain | Status | Notes |
|--------|--------|-------|
| Expressive Language | ☐ Typical ☐ Concern ☐ Delay | |
| Receptive Language | ☐ Typical ☐ Concern ☐ Delay | |
| Gross Motor | ☐ Typical ☐ Concern ☐ Delay | |
| Fine Motor | ☐ Typical ☐ Concern ☐ Delay | |
| Social-Emotional | ☐ Typical ☐ Concern ☐ Delay | |
| Cognitive | ☐ Typical ☐ Concern ☐ Delay | |
| Adaptive/Self-Help | ☐ Typical ☐ Concern ☐ Delay | |

## Section 8: Red Flags Observed

### Autism-Specific Red Flags
- [ ] Limited eye contact
- [ ] No response to name
- [ ] Limited or no pointing
- [ ] Limited social smiling
- [ ] Unusual sensory interests
- [ ] Repetitive behaviors
- [ ] Other: _______________

### General Developmental Red Flags
- [ ] Loss of previously acquired skills
- [ ] Significant delay in milestones
- [ ] Concerns about hearing or vision
- [ ] Asymmetric movements
- [ ] Parental intuition of concern
- [ ] Other: _______________

## Section 9: Risk Factors

- [ ] Prematurity (<37 weeks gestation: _____ weeks)
- [ ] Low birth weight (<2500g: _____ g)
- [ ] NICU admission
- [ ] Family history of developmental disorders
- [ ] Environmental risk factors (poverty, exposure)
- [ ] Medical conditions affecting development
- [ ] Other: _______________

## Section 10: Overall Screening Result

### Summary Result
- [ ] Passed - Development appears typical
- [ ] Monitoring - Some concerns, rescreening recommended
- [ ] Failed - Referral for comprehensive evaluation recommended

### Domains of Concern (if any)




## Section 11: Recommendations and Referrals

### Immediate Actions
- [ ] Routine developmental surveillance at next well-child visit
- [ ] Rescreening in _____ months
- [ ] Referral for comprehensive developmental evaluation
- [ ] Referral to Early Intervention (Part C Birth-to-Three)
- [ ] Referral to Preschool Special Education (Part B)
- [ ] Referral to specific services:
  - [ ] Speech-Language Therapy
  - [ ] Occupational Therapy
  - [ ] Physical Therapy
  - [ ] Audiology
  - [ ] Ophthalmology
  - [ ] Other: _______________

### Referrals Made

| Service/Provider | Referral Date | Contact Information |
|-----------------|---------------|---------------------|
| | | |
| | | |

### Parent Education Provided
- [ ] Age-appropriate developmental milestones discussed
- [ ] Activities to promote development reviewed
- [ ] Resources provided (handouts, websites, community programs)
- [ ] Follow-up plan explained

## Section 12: Parent Communication

### Discussion with Parent/Guardian
- Screening results explained: ☐ Yes
- Questions answered: ☐ Yes
- Recommendations discussed: ☐ Yes
- Written summary provided: ☐ Yes

### Parent Response
- [ ] Agrees with recommendations
- [ ] Has questions (documented below)
- [ ] Declines recommendations
- [ ] Requests additional information

### Notes




## Section 13: Follow-Up Plan

| Follow-Up Action | Responsible Person | Target Date |
|------------------|-------------------|-------------|
| | | |
| | | |

## Section 14: Signatures

| Screener Signature | | Date | |
|-------------------|---|------|---|
| Reviewed By (Provider) | | Date | |
| Parent Acknowledgment | | Date | |

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*Form FRM-SCR-001 Rev 1.0*