Autism Assessment Clinic
Autism Assessment Clinic
Medical Examination Report
Autism Assessment Clinic – Medical Examination Report
Review of Medical History from Neurodevelopmental History
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Parental Concerns
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Physical Examination
Height
Centile:
Weight
Centile:
Head Circumference
Centile:
Pulse
Blood Pressure
Cardiac Murmur
Yes
No
If yes, please detail:
Respiratory Assessment
Normal
Abnormal
If abnormal, please detail:
Dysmorphic Features evident
Yes
No
If yes, please describe:
Neurocutaneous markings i.e. cafe au lait spots/axillary freckles
Yes
No
If yes, please describe:
Strabismus
Yes
No
Wears glasses
Yes
No
Cataract
Yes
No
Hearing normal
Yes
No
Abdominal organomegaly evident
Yes
No
If yes, please describe:
Peripheral Power
Normal
Abnormal
If abnormal, please detail:
Co-ordination of movement
Normal
Abnormal
If abnormal, please detail:
Peripheral reflexes
Brisk
Normal
Reduced
Absent
If abnormal, please detail:
Spine
Normal
Abnormal
If abnormal, please detail:
Other information (if applicable):
Overall impression and Medical Opinion
Discussed with parents
Yes
No
Recommendations
Normal examination and therefore no further action required
Onward referral required to:
Parents advised to discuss with GP
Other
Paediatrician name and Signature
GMC Number
Date
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