Neurodevelopmental Evaluation Note (Developmental Delay/Regression)

Date: [Date]

Location: [Clinic or telehealth location]

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

Referring Clinician: [Name, credentials]

Reason for Referral: [Brief reason for referral]

Informant(s): [Names and relationships] (Specify relationship for each: parent, guardian, foster parent, teacher, therapist. Note language of interview and whether collateral reports were available.)

History Reliability/Limitations: [Factors affecting history quality] (Note interpreter use, communication barriers, limited records, conflicting reports, or other relevant factors. Omit if no limitations.)

Chief Concern

[One to three prioritized concerns] (Use caregiver wording in quotes when it captures the concern well.)

History of Present Illness

[Narrative synthesis of onset and course of concerns] (Include: who first noticed and when, trajectory [static delay / plateau / progressive decline], developmental domains affected, functional impact on daily living and caregiver burden, associated neurologic or systemic symptoms [seizures, sleep disturbance, feeding difficulties, gait changes, episodic lethargy], and relevant context [preceding illness or injury, psychosocial stressors, medication or toxin exposures]. If regression is suspected, summarize timeline here and note that details follow in Developmental History.)

Prenatal, Birth, and Neonatal History

• [Pregnancy complications and exposures] (Specify source for substance or teratogen exposure information.)
• [Gestational age, mode of delivery, perinatal complications]
• [NICU course, respiratory support, neonatal seizures, hypoxia, significant hyperbilirubinemia]
• [Newborn screening results or concerns]
• [Corrected age for preterm infants] (Include when applicable.)

Developmental History and Regression Screening

(Document milestone acquisition by domain. Note approximations explicitly and specify source: caregiver report vs external records.)

Gross Motor: [Milestone ages: head control, sitting, walking, running]; [Current abilities]; [Quality concerns: asymmetry, frequent falls, endurance]. Regression: [Yes / No / Unclear] (If Yes, describe skills lost, timing, and current status.)

Fine Motor: [Reach/grasp, pincer, drawing, utensil use, dressing]. Regression: [Yes / No / Unclear]

Language - Expressive: [Babbling onset, first words, word combinations, current level]. Regression: [Yes / No / Unclear] (Specify words or phrases lost if applicable.)

Language - Receptive: [Follows commands, understands routines, comprehension level]. Regression: [Yes / No / Unclear]

Social/Communication: [Joint attention, response to name, eye contact, peer interest, pretend play] (Describe behaviors rather than applying labels.) Regression: [Yes / No / Unclear]

Cognitive/Learning: [Problem-solving, imitation, attention, learning rate]. Regression: [Yes / No / Unclear]

Adaptive/Self-Help: [Feeding, toileting, dressing, sleep, safety awareness]. Regression: [Yes / No / Unclear]

Regression Summary: Regression present: [Yes / No / Unclear]. (If Yes: summarize skills lost, age of acquisition and loss, tempo [sudden / gradual], pattern [stepwise / continuous], current status [partial recovery / persistent], and associated features [seizures, illness, sleep disruption, behavior change]. If Unclear: state what information is missing and plan to obtain.)

Medical History

• [Relevant diagnoses: seizures, prior developmental diagnoses, hearing or vision impairment, sleep apnea, feeding disorders]
• [Hospitalizations and surgeries]
• [Head injuries]
• [Growth or nutrition concerns]
• [Recurrent infections or episodic decompensation]
• [Hearing screening/evaluation: status and results]
• [Vision screening/evaluation: status and results]

Medications and Allergies

Current Medications: [Medication, dose, frequency, indication] (List psychotropics and antiseizure medications clearly.)

Allergies: [Allergen and reaction type]

Family History

• [Developmental delay, intellectual disability, autism, learning disorders] (Specify confirmed vs reported.)
• [Seizures or epilepsy]
• [Known genetic syndromes or metabolic disorders]
• [Neurodegenerative disease or early-onset dementia]
• [Similar regression in relatives]
• [Consanguinity]
• [Pregnancy losses or infant deaths]

Social and Environmental History

• [Household composition and primary caregivers]
• [Languages spoken at home]
• [Childcare or school setting]
• [Barriers to care: transportation, therapy access, caregiver capacity]
• [Safety concerns: elopement risk, pica, self-injury] (Include when relevant to developmental status.)

Therapies, Services, and Educational Supports

(For each service, note source: therapy report reviewed vs caregiver report.)

• Service: [Early intervention / PT / OT / Speech therapy / Feeding therapy / Behavioral therapy]
  Setting: [Clinic / Home / School / Telehealth]; Frequency: [Frequency]; Start Date: [Date]
  Goals: [Current goals]; Response: [Progress and barriers]; Source: [Report reviewed / Caregiver report]

(Repeat for each service.)

School/Early Intervention Status: [For under 3: IFSP status. For 3 and older: grade, classroom type, IEP/504 status, eligibility category, service minutes, accommodations, prior school evaluations with dates]

Prior Testing Reviewed

(Distinguish "Reviewed today" from "Reported but not reviewed." For unreviewed items, preface with "Per parent report.")

• Developmental/Psychometric Testing: [Reviewed / Reported] — [Date, instruments, scores, interpretation]
• Speech-Language Evaluations: [Reviewed / Reported] — [Date, measures, results]
• OT/PT Evaluations: [Reviewed / Reported] — [Date, results]
• Audiology and Vision: [Reviewed / Reported] — [Date, results]
• Neuroimaging: [Reviewed / Reported] — [Date, modality, findings]
• EEG: [Reviewed / Reported] — [Date, type, findings]
• Laboratory/Metabolic Testing: [Reviewed / Reported] — [Date, tests, results]
• Genetic Testing: [Reviewed / Reported] — [Date, platform, results, VUS if applicable]

Review of Systems

(Focused neurodevelopmental and metabolic screen. Include targeted positives and key negatives relevant to differential.)

• Neurologic: [Spells, seizures, headaches, coordination, weakness, abnormal movements]
• Sleep: [Snoring, apnea, insomnia, frequent awakenings]
• GI/Feeding: [Dysphagia, reflux, vomiting, constipation, dietary restrictions]
• Metabolic red flags: [Episodic lethargy, fasting intolerance, regression with illness]
• Sensory: [Hearing concerns, vision concerns]
• Other systems: [As indicated]

Physical Examination

Vitals and Growth

• Height: [Value, percentile]; Weight: [Value, percentile]; BMI: [Value, percentile] (Include trajectory notation.)
• Head circumference: [Value, percentile] (Required when age-appropriate.)

General and Dysmorphology

• [Overall appearance]
• [Dysmorphic features and congenital anomalies]
• [Skin exam for neurocutaneous findings] (Describe lesions with size, number, location.)

HEENT

• [Head shape, fontanelle if relevant]
• [Vision and hearing behaviors]
• [Oral motor exam] (Include if feeding or speech concerns.)

Other Systems

[Cardiopulmonary and abdominal exam findings] (Include when indicated by syndromic concern, growth issues, or systemic features.)

Neurologic Examination

• Mental status: [Alertness, engagement]
• Cranial nerves: [Findings as feasible]
• Motor: [Bulk, tone (axial and appendicular), functional strength, involuntary movements]
• Reflexes: [Deep tendon reflexes, plantar responses, symmetry]
• Coordination: [Age-appropriate testing]
• Gait and balance: [Base, arm swing, toe/heel walking, tandem]
• Functional observations: [Sit-to-stand, running, stairs]

(For hypotonia or weakness: address Gowers sign, toe-walking, waddling gait, calf hypertrophy, tongue fasciculations. If elements deferred, document what was not assessed and plan to complete.)

Developmental-Behavioral Observations

[Narrative of observed behaviors: social reciprocity, response to name, joint attention, play level and flexibility, communication and gestures, speech intelligibility, echolalia if present, regulation during transitions, sensory behaviors. Include caregiver statement on whether today's behavior is representative.]

Standardized Screening Instruments

(Include only if administered or reviewed during this encounter.)

• [Instrument name/version]: Informant: [Informant]; Date: [Date]; Scores: [Scores/cutoffs]; Interpretation: [Interpretation]; Limitations: [Any limitations]

Assessment

Summary Statement

[Synthesis: age, presenting concerns, key developmental findings, regression status with characterization if present, salient exam findings, key records reviewed, immediate risk flags if any]

Problem List

1. [Problem] (Number in order of clinical priority.)

Etiologic Differential

• Genetic: [Considerations with rationale]
• Metabolic/Neurodegenerative: [Considerations with rationale]
• Structural: [Considerations with rationale]
• Epileptic Encephalopathy: [Considerations with rationale]
• Neuromuscular: [Considerations with rationale]
• Sensory/Toxic/Endocrine: [Considerations with rationale]
• Psychosocial/Educational: [Considerations with rationale] (Document objectively.)

(For each diagnosis under consideration, document supporting features and evidence still needed.)

Plan

Diagnostic Evaluation

• Genetic Testing: [Recommended tests with tiering rationale]; [Pretest counseling documented: potential outcomes, VUS possibility, parental testing]; [Genetics referral status]
• Metabolic Testing: [Tests ordered with rationale and urgency]
• Neuroimaging: [Indication, modality, sedation considerations, clinical question]
• EEG: [Indication, study type]
• Audiology and Vision: [Referral status]

Therapy and Developmental Intervention

• [Therapy referrals: SLP, OT, PT, feeding, behavioral] (Proceed without waiting for etiologic workup.)
• [Targeted goals for each therapy]
• [AAC evaluation if functional communication limited]

School and Early Intervention Coordination

• [Under 3: Early intervention referral or continuation; plan to share findings with IFSP team; consent status]
• [Age 3+: School evaluation recommendation or IEP review; requested evaluation areas; medical documentation plan; consent/ROI status]

Family Support and Care Coordination

• [Caregiver education provided]
• [Resource navigation and care coordination]
• [Caregiver priorities]
• [Safety planning if relevant: elopement, choking, seizure precautions]

Follow-Up

• [Results review timeline and responsible clinician]
• [Follow-up interval] (Regression warrants shorter interval.)
• [Red flags for urgent reevaluation: further skill loss, new seizures, rapid neurologic change]