Autism Assessment Clinic – Medical Examination Report

Review of Medical History from Neurodevelopmental History

Parental Concerns

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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