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Screening

Pediatric Developmental Screening Form

3 pages•14 fields•HIPAA-ready
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Pediatric Developmental Screening Form

Page 1 of 3

Child's Name
Jane Martinez
Date of Birth
03/15/1985
Child's Age (months)
0
Parent/Guardian Name
Jane Martinez
Gestational Age at Birth
Select an option...
Communication Milestones
Gross Motor Skills
Fine Motor Skills
Problem-Solving Abilities
Social-Emotional Skills
Developmental Concerns
Enter details here...
Current Therapies
Birth Complications
Option A
Option B
Option C
Provider Assessment Notes
Enter details here...
Submit
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The Pediatric Developmental Screening Form provides a structured, age-appropriate framework for evaluating children's developmental progress across key domains. Adapted from validated instruments including the Ages and Stages Questionnaire (ASQ), this form assesses communication and language development, gross and fine motor skills, problem-solving abilities, and personal-social interactions. Parents and caregivers complete milestone-specific questions that help clinicians identify potential developmental delays early.

The form is organized by developmental domains with clear, parent-friendly language that makes it easy for caregivers to accurately report their child's abilities. It includes sections for documenting birth history, prematurity adjustments, previous developmental concerns, and current therapies or interventions. Scoring guidance helps providers determine whether a child's development falls within expected ranges or warrants further evaluation.

Designed for pediatricians, family medicine providers, early intervention programs, and child development centers, this screening tool supports the AAP-recommended schedule of developmental surveillance at well-child visits. It facilitates early identification of developmental delays and timely referral to specialists, improving outcomes through prompt intervention.

What's included

  • Age-appropriate milestone checklists across five domains
  • Communication and language development assessment
  • Gross and fine motor skill evaluation
  • Problem-solving and cognitive screening questions
  • Social-emotional development indicators
  • Birth history and prematurity adjustment fields

Who uses this template

  • Well-child visit developmental surveillance per AAP guidelines
  • Early intervention program eligibility screening
  • Prematurity-adjusted milestone tracking for NICU follow-up
  • School readiness developmental evaluation

All form fields

14 fields across 3 pages. Customize any field after signing up.

Child's NameText
Date of BirthDate
Child's Age (months)Number
Parent/Guardian NameText
Gestational Age at BirthDropdown
Communication MilestonesCheckbox
Gross Motor SkillsCheckbox
Fine Motor SkillsCheckbox
Problem-Solving AbilitiesCheckbox
Social-Emotional SkillsCheckbox
Developmental ConcernsLong Text
Current TherapiesCheckbox
Birth ComplicationsMultiple Choice
Provider Assessment NotesLong Text
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