ASD Assessment

Consent

Informed verbal consent was obtained from this patient to communicate and provide care using virtual and other telecommunication tools. This patient has been explained the risks related to unauthorized disclosure or interception of personal health information and steps they can take to help protect their information. We have discussed the care provided through video or audio communication cannot replace the need for physical examination or an in-person visit for some disorders or urgent problems and patient understands the need to seek urgent care in an Emergency Department as necessary.

Appointment Details

Video conference appointment on [date] at [time].

INTRODUCTION AND PRESENTING CONCERNS

[Name] attended today's appointment with [his/her] [accompanying guardian/parent/adult]. [Document any diagnosis including details such as age of diagnosis, treatment history, and current treatment.] [He/she] has been referred for an ASD assessment as [he/she] has [document all symptoms mentioned related to autism, such as sensory issues, aversions to food textures, loud noises, touch, flapping their hands, gait abnormalities, speech impairment/delay]. [He/she] enjoys [discuss things the patient enjoys or likes doing].

CURRENT SERVICES

[He/she] is in grade [grade], and struggles with [document any academic difficulties or presence of individualized education program (IEP) including reason and any details discussed regarding this.] [He/she] has/doesn't have/never had [speech therapy, OT or Physiotherapy.]

Early language development

[Document any details regarding language development, including age at which they hit language milestones, and if the patient was babbling and engaging with others as an infant, for example making eye contact and smiling. Document if there were any language concerns as an infant/toddler/child, and if there was any regression mentioned. Document current language abilities and level.]

Reciprocity

[Document details regarding reciprocity in social interactions, both in infancy and throughout [his/her] development. E.g. how did [he/she] request things as an infant/toddler. Document whether [he/she] spontaneously shares information about [his/her] day or [himself/herself]. How easy is it to engage them in conversation. Does [he/she] have special interests that they talk about frequently or a lot. Does [he/she] smile at other people. Document whether [he/she] feels/shows affection and/or reciprocates affection. Document expression of emotions, angry outbursts. Does [he/she] respond to their name.]

Nonverbal communication

[Document whether [he/she] makes eye contact, looks at other people when they are talking to him, uses gestures, facial expressions, etc.]

Play

[He/she] enjoys [document patient's interests, what they like to do, if they enjoy playing etc.]. [[He/she] [does/doesn't] engage in pretend play and role play.]

Relationships

[Document whether [he/she] gets along with other kids/people their age, if there is any bullying, whether [he/she] has friends or are alone. Document relationship with family members, such as parents, siblings, and grandparents.]

Stereotypic, repetitive behaviours

[Document whether [he/she] flaps their hands when excited, or performs other repetitive movements/behaviors, such as banging their head, lining up toys or objects, repetitive sounds etc.]

Transitions, Temper tantrums, Routines and Rituals

[Document information about: temper tantrums, angry outbursts. Include details. Is [he/she] able to communicate what's wrong. How does [he/she] manage transitions or change. What are [his/her] routines.]

Perseverations/Attachments

[He/she] is attached to [object]. [Document if the patient has a strong attachment or interest in an object or topic.]

Sensory issues

[He/she] is sensitive to [document sensory sensitivities, e.g. loud sounds, touch, textures, certain foods/food textures, dirt, etc.]. [Record all sensory issues discussed]

Anxiety

[He/she] is afraid of [patient's fears]. [Document any other information discussed regarding anxiety.]

Hyperactivity/Inattention

[Document whether [he/she] is hyperactive and/or inattentive. If there is a diagnosis of ADHD document medications, if relevant.]

DEVELOPMENT AND ADAPTIVE SKILLS

[Document developmental history, including details and whether there are concerns from parents, family members, teachers, or others. Include information about personal care and hygiene routines, and sense of danger.]

Cognitive & Pre-Academics

[He/she] is going to grade [grade] in [type of school, including name if mentioned]. [He/she] is struggling with academics. [Document details regarding academic issues, any adaptations made, current grades if discussed, and specific cognitive issues patient experiences.]

PAST MEDICAL HISTORY

[Document birth history and neonatal issues, as well as any co-morbidities and past medical history.]

FAMILY HISTORY

[Document information regarding people in the household, as well as family history of medical or psychiatric conditions. Include family history of autism or ADHD.]

Chief Complaint

[ASD Assessment]

PHYSICAL EXAM

Weight: [weight] Percentile: [weight percentile] Height: [height] Percentile: [height percentile] [Document physical exam findings.]

Assessment and Plan

Assessment and Plan