PCN/Developmental Pediatrics Clinic ASD Focused Health ...

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Date of Interview PATIENT INFORMATION Name MRN DOB Age Parent/Guardian

PCP Referring Provider

RELEVANT BACKGROUND HISTORY BIRTH HISTORY Pregnancy was Complicated UncomplicatedSpecifically, Child was born at ____ weeks via Vaginal C-SectionChild’s hospital course was was not significant Specifically,

HEALTH HISTORYChild has been diagnosed with Delayed milestones Global developmental delay Intellectual disability ADHD Language disorder Anxiety Depression OtherOther health concerns include Relevant family diagnoses include

EARLY DEVELOPMENTAL MILESTONESChild’s motor milestones were early on time slightly delayed significantly delayedIncluding: Sitting alone at ______ months

Crawling at _______ months Walking at _______ months

Specifically, Child’s language and communication

early on time slightly delayed significantly delayed

Including: Did Did not babble and vocalize often Said “mama”/ “dada” at ____ months Said other words at ____ months Started talking in multiple word phrases at ____ months

Specifically, Parents Did Did not have concerns about child’s social development during infancy. Including: Did Did not have a social smile

Did Did not “light up” when someone played or engaged with him/her Did Did not have good eye contact Did Did not track parents when they moved

Specifically,

SLEEP HISTORYThere are are not concerns about sleep Child goes to bed at ________ and takes ________________ to fall asleep.

Parents

have have not noticed that child has sleep problems Sleep symptoms: Difficulty falling asleep Nighttime awakening Snoring Sleep apnea Daytime drowsiness Nightmares Restless sleep OtherChild wakes up at ________ in the morning and is easy difficult to wake. Specifically,

PCN/Developmental Pediatrics Clinic ASD Focused Health/Developmental History | Ages 6+

MEDICATION HISTORY for Child previously took

Amounts for Child currently takes

Amounts Any side effects:

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PCN/Developmental Pediatrics Clinic ASD Focused Health/Developmental History | Ages 6+

DIETARY/FEEDING HISTORY There are are not concerns about feeding.

Examples: Negative meal time behavior Oral motor difficulties Limited intake Limited Variety OtherSpecifically,

TOILETING HISTORYThere are are not concerns about toileting.

Examples: Constipation Encopresis Daytime wetting Toilet training concerns GI issues OtherSpecifically,

SCHOOL HISTORYChild att

en

ds school at ____________________________________ and is in ____________ grade.

Child currently does does not has a 504 Plan/IEP. Child’s teachers report

PREVIOUS EVALUATION/TREATMENT HISTORYChild currently has has not participated in private therapies. Including: Speech therapy Occupational therapy Physical therapy Cognitive behavioral therapy

Play therapy Social skills group ABA For approximately ________ years.

As a baby, child’s temperament was feeding was sleeping was

Child did did not have a regression of skills.Specifically,

COMMUNICATION SKILLS When child was 4 or 5, how did he/she attempt to communicate/get needs met?

waving thumbs up reaching Pointing

No Yes Yes

Using pointing only to request Sometimes

No

Respond to name Make appropriate eye contact Use caregiver’s hand/body as a tool Nod/shake head for yes/no Use other conventional gestures, such as

Using points to request and showWith integrated eye contactDid you have to teach child to point

Descriptive gestures Emphatic gestures

Specifically, did the child

If yes, attached to referral: yes no

DEVELOPMENTAL AND SOCIAL COMMUNICATION HISTORY The following information was gathered through a combination of chart review and targeted clinical interview with the family on (date) __________________. Of note, this interview had a particular emphasis on social communication skills and the presence of restricted and repetitive behaviors to determine if child’s behavioral presentation is consistent with a medical diagnosis of autism spectrum disorder. Best practice indicates collecting a comprehensive developmental history addressing these areas. Below is a summary of the comprehensive interview conducted with (parents/caregivers present) ___________________________________.

Was the child present for and/or participated in the interview? yes no

Family/caregivers first became concerned about child’s development around the age of ________ due to

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PCN/Developmental Pediatrics Clinic ASD Focused Health/Developmental History | Ages 6+

Show emotionally nuanced facial expressions Use repetitive language Script lines from television/movies at unusual times Pronoun (“You” / “I”) reversal Refer to self in the third person Insist on using made up words

Current communication skills Nonverbal Jargon Signs Word approximation/single word Phrase speech Complex/fluent speech

Currently, does the child demonstrate any of the following differences in his/her verbal communication skills: Repetitive language Echolalia Scripting lines from television/movie lines at unusual times Refer to self in the third person Insist on using made up words Unusually formal speech Excessive detail in conversation Unusual or restricted prosody/tone

For example,

Specific social and play skills When the child was 4 or 5, did he/she:

Offer to share object Offer comfort if someone else was sad/hurt Spontaneously join in social and/or cooperative games Have true friendships

Currently, child’s nonverbal communication skills are: limited less than expected appropriate and well integrated

Specifically, concerns were noted in the following areas: Reduced eye contact Limited gesture use Exaggerated/stiff gesture use Unusual or socially inappropriate facial gestures Other

For example,

Currently, child demonstrates the following concerns related to social interaction skills: Limited interest in peers Difficulties in following others’ lead in conversation Difficulty with conversational reciprocity Difficulties recognizing social cues Difficulties initiating peer relationships Difficulties sustaining peer relationships Getting along better with younger children or older children/adults Other

For example,

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PCN/Developmental Pediatrics Clinic ASD Focused Health/Developmental History | Ages 6+

Interests & Routines, Unique Behaviors, Sensory When the child was 4 or 5, did he/she: Currently, does the child demonstrates the following concerns related to behavioral rigidity? If yes,

please provide comments. Insist on certain routines Yes No Become upset with small changes to

unexpected routines such as needs todrive the same way home every day

Yes No

Have a need for sameness Yes No Have difficulty with transitions Yes No

Intense interests When the child was 4 or 5, did he/she have intense interests, including:

Currently, does the child demonstrate the following concerns related to specific interests? If yes, please provide comments.

Thomas the Train Minecraft Dinosaurs Space History Cars Construction equipment Anime Roblox Animals Other:

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

Unusual interests When the child was 4 or 5, did he/she have unusual interests?

Currently, does the child demonstrate concerns related to specific interests? If yes, please provide comments.

Yes No

Currently, does the child demonstrate concerns related to interest in the parts of a toy rather than the full object? If yes, please provide comments.

Yes NoFor example:Interest in the parts of toys rather than the full object?

No Yes No Yes For example:

Repetitive behavior When the child was 4 or 5, did he/she demonstrate the following repetitive behaviors?

Currently, does the child demonstrate the following repetitive behaviors? If yes, please provide comments.

Hand flapping Pacing Toe walking Posturing Spinning Lining up objects Spinning objects Other

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

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PCN/Developmental Pediatrics Clinic ASD Focused Health/Developmental History | Ages 6+

History of regression: Child’s parents do do not Report a history of regression in developmental milestones.

Mood, Attention, and Behavior Concerns Are there any concerns about child’s behavior, mood, anxiety, attention/activity level?

Mood concerns Child’s typical mood is:

Cries frequently Yes No

Becomes upset over little things Yes No

Seems to be in a down mood often No His/her down moods occur _________ times a

Yes day week month

And last for _________ minutes

Has angry outbursts Yes No His/her outbursts occur _________ times a day week month And last for _________ minutes

At this time, he/she Triggers Being told “No” Not getting his/her way

Change in routine Being asked to stop a preferred activity Being asked to do something less preferred Sibling Unconnected to triggers or seems like a mood change Homework Other

Anxiety concerns Seems anxious or worried or avoid things for no apparent reason Yes NoFor example:

Obsessions/Compulsions Repeats actions over and over Yes No

Seems to have repetitive thoughts that are upsetting to him/her Yes No

Sensory sensitivities or interests When the child was 4 or 5, did he/she demonstrate the following?

Currently, does the child demonstrate the following sensitivities or interests? If yes, please provide comments.

Seems under sensitive to pain Sensitive to loud noises, bright light,odors Frequently smells objects Sensitive to certain textures Engages in visual inspection Puts non-food items in mouth

For example:

Yes No Yes No

Yes No Yes No Yes No Yes No

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PCN/Developmental Pediatrics Clinic ASD Focused Health/Developmental History | Ages 6+

Attention/Activity concerns Has difficulty paying attention Yes No

Seems very active Yes No

Is easily distracted Yes No

Thought concerns Seems to hear/see things that are not there Yes No

Seems to have unusual beliefs or ideas Yes No

Stressors/Trauma

Safety Parents did did not endorse concerns related to safety. Examples

In your judgment, does this child’s behavioral presentation meet criteria for autism spectrum disorder? Yes No

How certain are you of this diagnosis? Highly uncertain Uncertain Certain Highly certain

Elopement Running away from home Wandering Poor stranger awareness Dangerous impulses Suicidal ideation Homicidal ideation Other:If/How did you address these concerns during the visits? Is there a current “plan?”

Did you discuss concerns for ASD with the parent? Yes No

Were those concerns discussed in front of the child and/or directly with the child during the visit? Yes No