Global Developmental Delay/Intellectual Disability Evaluation Note

Header

Patient: [Patient name]; [Date of birth]; [Medical record number]

Date/Time: [Encounter date and time]

Visit Type: [new / follow-up]; [consult / primary]

Referring Clinician: [Referring clinician name and specialty]; [Referral question if provided]

Historian(s): [Historian(s) and relationship]; [Interpreter used: [yes / no]; Language: [Language if applicable]]

Records Available: [List school evaluations, IEP, EI reports, prior specialty notes, imaging/labs available at time of visit]

Reliability: [Brief statement on history reliability and any limitations]

Reason for Visit

[Concise statement (1–3 sentences) including caregiver's wording in quotes when available, functional impact, and goals for the visit (diagnosis, etiology, school supports, services, prognosis)]

History

Developmental Concern Narrative

[Narrative of onset and course of concerns; whether delays noted since infancy vs recognized later; plateau or regression status [present / absent / uncertain] with details if present; domains of concern (gross motor, fine motor, speech/language, cognition, social communication, adaptive/self-help); current functional limitations with concrete examples; contextual factors (bilingual environment, schooling consistency, trauma/stressors, sleep problems, seizures, hearing/vision issues); summary of prior interventions and response]

(Use cohesive paragraph format. Explicitly document presence or absence of skill loss. Distinguish caregiver report from clinician observation.)

Developmental Milestones

(List age achieved or "not yet." Use "Unknown" if not obtained. Label caregiver estimates as estimates.)

• Gross motor: [Head control]; [Independent sitting]; [Crawling]; [Pull to stand]; [Independent walking]; [Running]; [Stairs]
• Fine motor: [Reach/grasp]; [Pincer grasp]; [Pointing]; [Scribbling/drawing]; [Utensil use]; [Buttons/zippers]; [Dressing skills]
• Speech/language: [Babbling]; [First words]; [Two-word phrases]; [Sentence use]; [Speech intelligibility]; [Receptive language level]
• Social/play: [Joint attention]; [Gestures]; [Pretend play]; [Peer interaction]
• Adaptive: [Feeding skills]; [Toileting]; [Dressing]; [Hygiene]; [Safety awareness]
• Regression: [present / absent / uncertain]; [If present: domain(s) affected, age at loss, precipitating factors if known]

Adaptive Functioning

(Required when ID is suspected. Provide concrete examples. Compare home vs school vs community. Document support needs including supervision level, prompting, accommodations.)

• Conceptual: [Following routines; pre-academic/academic skills; problem-solving; time/money concepts as age-appropriate]
• Social: [Social reciprocity; friendships; behavior in groups; social understanding]
• Practical: [ADLs/IADLs—feeding, toileting, dressing, hygiene; safety; community participation; required supervision; prompting/accommodations]
• Standardized adaptive testing: [Instrument name]; [Date]; [Reporter]; [Domain scores with metrics]; [Plain-language interpretation]; [Validity considerations] (Include if available)

Educational and Therapy History

• Early intervention (birth–3): [Entry age]; [Services received]; [Frequency/intensity]; [Discharge date/status]
• School: [Current grade]; [Placement (general ed / special day class / other)]; [IEP / 504 / neither]; [Eligibility category if applicable]; [Classroom supports]
• Related services: [Speech]; [OT]; [PT]; [Behavior support]; [AAC]; [Other] with [Frequency]
• Attendance/stability: [Missed school; moves; interruptions; access barriers]

Prior Testing Summary

(Summarize each evaluation succinctly. May use compact list or table format.)

• [Test name]; [Date]; [Examiner/discipline]; [Key scores (standard scores/percentiles)]; [Validity concerns]; [Conclusions/interpretation]
• (Add additional items as needed)

Birth and Perinatal History

• Pregnancy: [Complications]; [Maternal illnesses]; [Medications]; [Exposures: alcohol / tobacco / drugs / teratogens]
• Prenatal testing: [Screening/diagnostic results if known]
• Delivery: [Mode]; [Complications]
• Gestational age: [Weeks]
• Birth weight: [Weight and percentile if known]
• Neonatal course: [NICU stay]; [Jaundice]; [Feeding issues]; [Newborn screen results]

Medical History

• Neurologic: Seizures/spells: [present / absent]; [If present: semiology, frequency, triggers, last event]; [Headaches]; [Tone/coordination concerns]
• Growth/nutrition: [Feeding difficulties]; [Failure to thrive / obesity / normal growth]; [Other]
• Sleep: [Snoring/apnea]; [Insomnia]; [Night awakenings]; [Sleep quality]
• Hearing/vision: [Prior screens with dates/results]; [Glasses/hearing aids]; [Concerns]
• Gastrointestinal: [Constipation]; [Reflux]; [Swallowing concerns]
• Behavioral/psychiatric: [ADHD symptoms]; [Anxiety/mood]; [Self-injury]; [Aggression]; [Elopement]; [Sensory sensitivities]
• Other medical conditions: [Relevant conditions]

Medications: [Medication]; [Dose]; [Schedule]; [Indication]; [Response/side effects]

Allergies: [Drug/other allergies]; [Reaction type]

Family History

[Three-generation summary of neurodevelopmental conditions: intellectual disability, learning disorders, autism, language disorders, epilepsy, psychiatric illness, congenital anomalies, known genetic diagnoses; consanguinity [present / absent]; pertinent negatives]

Social History

[Household composition; primary caregivers; custody/foster involvement; primary language(s) and interpreter needs; environmental factors (lead exposure risk, housing stability); screen time and learning opportunities; adverse experiences as clinically relevant]

Review of Systems

(Targeted. Brief positives and pertinent negatives.)

• Neurologic: [Positives/negatives]
• Sleep: [Positives/negatives]
• Vision/Hearing: [Positives/negatives]
• Gastrointestinal: [Positives/negatives]
• Growth: [Positives/negatives]
• Behavioral: [Positives/negatives]

Objective

Vitals and Growth

• Height/Weight/BMI: [Values with percentiles]
• Head Circumference: [Value with percentile] (Required for young children; include for older children when clinically relevant)
• Blood Pressure: [Value and percentile if obtained]

Physical Examination

• General: [Appearance; interaction; distress level]
• Dysmorphology: [Facial features; ears; palate; hands/feet; posture/gait] (Include when syndromic concern present)
• Skin: [Neurocutaneous findings (e.g., café-au-lait macules, hypopigmented macules)]
• HEENT/Cardiac/Abdomen: [Pertinent findings]
• Musculoskeletal: [Contractures; scoliosis; joint laxity if relevant]

Neurologic Examination

• Mental status/engagement: [Findings]
• Cranial nerves (gross): [Findings]
• Tone: [Findings]
• Strength: [Findings]
• Reflexes: [Findings]
• Coordination: [Findings]
• Gait: [Findings]
• Abnormal movements/lateralizing signs: [Findings]

Developmental and Behavioral Observations

[Direct observations during the visit: communication (eye contact, gestures, speech, comprehension); social reciprocity; play skills; attention/activity level; transitions; sensory behaviors; motor planning; safety behaviors]

(Clearly distinguish observations from caregiver report.)

Testing Performed Today

(Include only if standardized instruments were administered; otherwise omit this section.)

• [Tool name and version]; [Language]; [Accommodations]; [Validity considerations]; [Scores with metrics]; [Plain-language interpretation]; [Reporter for rating scales]

Data Reviewed

[Summary of external records reviewed with clinical significance: source type, date, key findings, and how it informs today's assessment/plan; explicitly note critical missing records and plan to obtain them]

Assessment

Diagnostic Summary

[Synthesis stating whether presentation fits global developmental delay vs suspected/confirmed intellectual disability vs specific domain delays; severity framed by adaptive impact; suspected/identified comorbidities (e.g., autism spectrum features, ADHD, epilepsy, cerebral palsy, language disorder, hearing loss); explicit statement on regression [present / absent]; urgent red flags if any]

(Avoid definitive ID diagnosis unless evidence supports both intellectual and adaptive impairment with developmental onset. Otherwise use "concern for" or "suspected" and specify missing evidence.)

Problem List

1. [Problem 1: Developmental diagnosis and functional impact]
2. [Problem 2: Comorbidity or safety concern]
3. [Problem 3: Additional active medical/behavioral issue]

Etiologic Differential

(Include when etiologic workup is being considered. Brief, linked to patient-specific features.)

• Genetic/chromosomal: [Items and rationale]
• Prenatal/perinatal: [Items and rationale]
• Structural brain: [Items and rationale]
• Metabolic: [Items and rationale]
• Sensory: [Items and rationale]
• Environmental/psychosocial: [Items and rationale]

Plan

(Problem-oriented format. Specify what is ordered, deferred with rationale, and who is responsible.)

Diagnostic and Etiologic Evaluation

Genetics: [Testing completed]; [Testing ordered today (e.g., chromosomal microarray, Fragile X, exome/genome if indicated)]; [Deferred and rationale]; [Pre-test counseling documented: purpose/limitations, possibility of variants of uncertain significance, secondary/incidental findings, family implications, consent obtained, plan for return of results]

Neuroimaging: [Indication and modality (e.g., MRI brain)]; [ordered / deferred with rationale]; [Sedation considerations]

EEG: [Indication]; [ordered / deferred with rationale]

Metabolic Testing: [Indications/red flags (e.g., regression, episodic decompensation)]; [Tests ordered (e.g., lead, thyroid, targeted metabolic/nutritional studies)]; [Deferred with rationale]

Sensory Evaluation: [Audiology referral status]; [Ophthalmology/optometry referral status]; [Rationale and timing]

Referrals: [Specialty/service]; [Specific clinical question]; [Urgency]

Therapeutic and Educational Recommendations

• [Early intervention or school-based special education: referral status and timelines]
• [Speech-language therapy; AAC evaluation if speech is limited]
• [Occupational therapy for fine motor, sensory needs, ADLs, feeding]
• [Physical therapy for gross motor, balance, orthotics]
• [Behavioral supports: parent training, functional behavior assessment, safety planning]
• [IEP recommendations: goals, accommodations, supports, assistive technology]
• [Adaptive skills training: specific targets]

Safety and Family Support

(Include when relevant.)

• [Elopement/wandering precautions; water safety; environmental modifications]
• [Strategies for self-injury/aggression]
• [Caregiver support resources; respite; social work referral]

Follow-Up and Coordination

• Results management: [Who reviews results and how family will be notified]
• Follow-up timeframe: [Timeframe]; (Return sooner if regression, seizures, or new neurologic signs)
• Records to obtain: [List]; [Consent status]
• Communication: [Plan to update primary care and other providers]