developmental-pediatrics/Forms/Screening-Results/FRM-SCR-001-Developmental-Screening-Summary.md

Developmental Screening Summary Form

Form ID	FRM-SCR-001	Revision	1.0

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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