Autism Diagnostic Evaluation Note (Developmental-Behavioral Pediatrics)

Date: [Date of evaluation]

Location: [in-person / telehealth]

Visit Type: [new diagnostic evaluation / follow-up diagnostic evaluation]

Patient Name: [Full name]

DOB: [Date of birth]

MRN: [Medical record number]

Evaluator(s): [Names and credentials]

Primary Informant(s): [Names and relationship to patient]

Language/Interpreter: [Primary language]; Interpreter: [yes / no] (If yes, include interpreter language and modality.)

Reason for Evaluation

[Referral question in one sentence]

• [Caregiver concern in their own words]
• [Caregiver concern in their own words]
• [Family goals for evaluation]

(Include 2–5 concerns. Use brief direct quotes only when particularly illustrative.)

Referral source: [Referring clinician/agency and reason for evaluation at this time]

Evaluation Methods & Data Sources

• [Caregiver interview completed]
• [Direct child observation completed] (Specify settings/contexts.)
• [Record review completed]
• [Standardized measures administered]
• [Collateral contacts] (Include only if completed; specify who and role.)

Records Reviewed:

• [Document type] — [Source], [Date]
• [Document type] — [Source], [Date]

[Key records requested but unavailable] (Include only if applicable.)

[Limitations affecting diagnostic certainty] (Include only if applicable, e.g., incomplete cross-setting data, limited cooperation, language/cultural factors.)

Developmental & Medical History

Prenatal/Perinatal: [Brief summary] (If unknown, state "Unknown.")

Early Motor Development: [Milestone timing and quality]

Speech-Language Development: [First words/phrases, receptive/expressive profile, quality of communication]

Social Development: [Response to name, joint attention, pointing/showing, play development]

Regression: [Any loss of skills with timing and context] (If none, state "No regression reported.")

Medical History: [Relevant conditions including seizures, sleep, feeding, sensory concerns, chronic conditions]

Medications: [Current medications and doses] (If none, state "None.")

Allergies: [Medication/food/environmental allergies] (If none, state "NKDA.")

Autism-Specific Symptom History

Social Communication and Interaction

• Social-emotional reciprocity (A1): [Back-and-forth conversation/play, sharing enjoyment, initiating/responding to social bids — with examples, frequency, and functional impact]
• Nonverbal communication (A2): [Eye gaze, facial expressions, gestures, body orientation — with quality, consistency, and impact]
• Relationships (A3): [Peer interest, friendship skills, adjusting behavior to context, imaginative play with others — with examples and functional impact]

Restricted and Repetitive Behaviors

• Repetitive movements/speech/object use (B1): [Stereotypies, echolalia/scripting, repetitive object use — with frequency, triggers, and interference]
• Insistence on sameness (B2): [Routines, difficulty with transitions, ritualized patterns — with response to changes and impact]
• Restricted interests (B3): [Topics/objects, intensity, time spent, interference with function]
• Sensory differences (B4): [Hyper/hyporeactivity, seeking/avoidance by sensory modality, safety and functional impacts]

Adaptive Functioning, Safety, and Behavioral Concerns

Daily Living Skills

Dressing: [Level of independence, supports needed] | Toileting: [Status, continence, supports] | Feeding: [Food repertoire, texture tolerance, mealtime behaviors] | Sleep: [Onset, maintenance, routines, daytime impact]

Safety Concerns

[Elopement/wandering, pica, danger awareness, self-injury, aggression — include frequency, triggers, severity for each applicable concern] (If no safety concerns, state "No safety concerns identified.")

Behavioral and Emotional Concerns

[Attention/hyperactivity, anxiety, mood/irritability, tics — include settings, triggers, and impairment for each applicable concern] (If none, state "No significant behavioral or emotional concerns reported.")

Educational History

Placement: [Current educational setting/grade/classroom type]

IEP/504: [Status, eligibility category, goals summary]

Services: [Speech-language, OT, behavioral supports — with frequency if known]

Teacher input: [Concerns and strengths reported by teachers, with date/source]

(Include this section for school-aged children and those in daycare.)

[Safety screening results] (Include only if developmentally appropriate and clinically indicated.)

Family and Social History

Family history: [ASD, language/learning disorders, ADHD, intellectual disability, psychiatric conditions — pertinent positives and negatives]

Social context: [Household composition, cultural/linguistic factors affecting symptom interpretation or service access] (Include only if material to assessment.)

Behavioral Observations

(Document directly observed behaviors during the evaluation. Clearly distinguish from reported history.)

Context(s): [Waiting room / unstructured play / structured tasks / transitions]

• Engagement & rapport: [With examiner and caregiver]
• Communication: [Spontaneous speech, AAC use, communicative intent, clarity]
• Eye gaze & gestures: [Quality, frequency, integration with speech]
• Affect: [Range, congruence, modulation]
• Play: [Symbolic/functional play, flexibility, shared play]
• RRBs/sensory responses: [Observed stereotypies, sensory seeking/avoidance]
• Attention & activity level: [Sustained attention, distractibility, hyperactivity]
• Response to transitions/frustration: [Coping strategies, supports needed]
• Response to social bids/joint attention: [Initiation, response, following gaze/points]

Standardized Measure Results

Autism-Specific Tools

Measure	Informant/Module	Date	Scores	Interpretation
[Measure name]	[Informant/Module]	[Date]	[Scores]	[Interpretive range]

Developmental/Cognitive Measures

Measure	Examiner/Form	Date	Scores	Interpretation
[Measure name]	[Examiner/Form]	[Date]	[Scores]	[Interpretive range]

Language Assessment

Measure	Examiner/Form	Date	Scores	Interpretation
[Measure name]	[Examiner/Form]	[Date]	[Scores]	[Interpretive range]

Adaptive Functioning

Measure	Informant	Date	Scores	Interpretation
[Measure name]	[Caregiver/Teacher]	[Date]	[Standard scores by domain]	[Interpretive range]

(For any category without available results, state: "No recent results available; additional evaluation [recommended / not indicated].")

Interpretive Summary: [Brief integrative comments on convergence/divergence of results, test validity, and functional implications]

Assessment and Diagnostic Formulation

[Integrated narrative synthesis of developmental history, observed behaviors, standardized results, cross-setting information, and functional impact] (1–2 paragraphs; maintain strength-based, family-centered tone.)

Strengths and Needs Profile

Strengths: [Communication strengths, interests/motivators, effective supports, protective factors]

Needs: [Core support needs across settings, barriers to participation, priority functional targets]

DSM-5 ASD Criteria Mapping

Criterion	Evidence	Sources	Met?
A1 Social-emotional reciprocity	[Behavioral examples with frequency and impact]	[History / Observation / Records]	[yes / no]
A2 Nonverbal communication	[Behavioral examples with frequency and impact]	[History / Observation / Records]	[yes / no]
A3 Relationships	[Behavioral examples with frequency and impact]	[History / Observation / Records]	[yes / no]
B1 Repetitive movements/speech/object use	[Behavioral examples with frequency and interference]	[History / Observation / Records]	[yes / no]
B2 Routines/sameness	[Behavioral examples with triggers and interference]	[History / Observation / Records]	[yes / no]
B3 Restricted interests	[Topics/objects with intensity and interference]	[History / Observation / Records]	[yes / no]
B4 Sensory differences	[Modalities with reactivity pattern and functional impact]	[History / Observation / Records]	[yes / no]
C Early developmental period	[Onset timing or masking until demands increased]	[History / Records]	[yes / no]
D Clinically significant impairment	[Affected domains: social, academic, adaptive, family]	[History / Observation / Records]	[yes / no]
E Not better explained by ID alone	[Social-communication relative to developmental level]	[History / Observation / Records]	[yes / no]

Diagnostic Determination, Support Levels, and Specifiers

ASD Diagnosis: [Criteria met / Criteria not met / Deferred]

• Social communication support level: [Level 1 / Level 2 / Level 3] — [Functional justification]
• Restricted/repetitive behaviors support level: [Level 1 / Level 2 / Level 3] — [Functional justification]
• Intellectual impairment: [without / with] — [Supporting data]
• Language impairment: [without / with] — [Expressive/receptive levels, pragmatic summary]
• Associated medical/genetic conditions: [List or "None known"]
• Associated neurodevelopmental/mental disorders: [List or "None"]

Differential Diagnosis

(Include only when diagnosis is uncertain or ruling out alternatives is clinically relevant.)

• [Differential considered] — [Supporting/refuting evidence and reasoning]
• [Differential considered] — [Supporting/refuting evidence and reasoning]

Co-Occurring Conditions

Confirmed diagnoses: [List conditions diagnosed today or previously confirmed]

Suspected/Rule-out: [List conditions requiring further evaluation with planned next steps]

Recommendations

(Prioritize actionable recommendations. Specify what, who, and when. Tie to identified needs and strengths.)

Therapy and Intervention

• [Behavioral intervention recommendation with focus area, provider type, and rationale]
• [Speech-language therapy recommendation with focus and rationale]
• [Occupational therapy recommendation with focus and rationale]
• [Mental health supports with focus and rationale]

School/Educational

• Share evaluation report with school team with caregiver consent
• [IEP/504 eligibility recommendation with suggested supports]
• [Behavior support plan recommendation if indicated]
• [Communication supports recommendation if indicated]

Medical Workup and Referrals

• [Genetics evaluation recommendation if indicated]
• [Hearing/vision screening if not current]
• [Specialty referrals based on presentation: sleep, feeding, neurology, psychiatry]

Safety Planning

[Specific mitigation strategies for identified safety concerns: elopement, self-injury, aggression] (Include only if safety concerns identified above.)

Family Supports

• [Care coordination/case management]
• [Parent training/support groups/respite referrals]
• [Benefits navigation if applicable]

Follow-Up

Timing: [Follow-up interval based on complexity and urgency]

Follow-up agenda: [Review of new records/testing, response to interventions, school updates]

Report distribution: [Recipients with consent]

[If diagnosis deferred: state additional information needed, interim supports to proceed, and reassessment timeframe]