Autism ADHD Template

Primary Care Autism and ADHD Assessment Template

Created by Dr Abdul Latif Saad
Klinik Kesihatan Presint 18, Putrajaya
How to use this Autism / ADHD clerking template
  1. Complete Sections A–G including history, development, behaviour, red flags, and screen time.
  2. In Section I – Diagnostic Checklist, tick criteria for ASD, ADHD, GDD/ID, and SLD.
  3. Click “Compute diagnosis” to automatically calculate criteria and see the colored summary.
  4. In Section J, select referrals (OT or Speech). The specific referral details will appear below the checkbox.
  5. For OT/ST referrals, complete the fields inside the detail box and click the relevant Print Form button inside that box.
  6. In Section K, click “Generate medical note” to auto-create a clinical note that can be copied to your clinic system.

This template is designed to support primary care clinicians in early assessment of children with developmental delays, autism spectrum disorder, ADHD, and learning difficulties.

A. Patient & Visit Details
B. Main Concerns & Red Flags
Main concerns (in parent's / teacher's own words, age of onset, previous consult/therapy)
18 months
24 months
3 years
Notes

Note: Compute diagnosis / criteria summary akan dibuat di Part 2.

C. Birth & Perinatal History
D. Developmental History (refer to milestone checklist)

Ask systematically for each domain. Note age of attainment, any delay or regression, and compare with expected milestones.

Enter NRIC or date of birth to show age-matched milestones.
Based on Paediatric Protocols for Malaysian Hospitals, Chapter 3. Earlier milestones remain available below for back-review.
E. Medical, Surgical & Family Background
F. Social, Education & Functional History
G. Diet, Sleep, Behaviour & Screen Time
H. Physical Examination
Centile: -
Centile: -
Centile: -
BMI-for-age centile: pending BMI table
Uses sex-specific 0-2, 0-5, or 2-20 years growth references based on age.
System Normal Abnormal Notes / Findings
General condition & appearance
Skin
Ears
Eyes
Oral cavity
Respiratory
Heart
Abdomen
Neurology
I. Diagnostic Checklist (ASD / ADHD / ID / Specific Learning Disorder)

Tick criteria based on FMS developmental checklist. Use the Compute diagnosis button to see which set of criteria is fulfilled.

1. Autism Spectrum Disorder (ASD)
A. Impairment in social communication & interaction (all 3)
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B. Restricted & repetitive patterns (≥2)
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2. Attention Deficit Hyperactivity Disorder (ADHD)
A1. Inattention (≥6)
A2. Hyperactivity / Impulsivity (≥6)
3. Global Developmental Delay / Intellectual Disability
A. GDD (under 5 years)
B. Intellectual Disability
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4. Specific Learning Disorder
A. Difficulties learning & using academic skills (≥1 for ≥6 months)
Diagnosis Summary
No criteria computed yet. Tick relevant boxes then click “Compute diagnosis”.
J. Management Plan & Referrals

Check the boxes above to reveal specific referral details.

K. Auto-generated Medical Note

This note will summarise the clerking, examination and provisional diagnosis in English. You can edit after generation and copy into the clinic system.

L. AI Referral Letter Generator (OpenAI)

Note: Make sure you have clicked "Generate medical note" in Section K first. The AI will use the information from that note to write the official referral letter.

Usage Today: 0 / 200
Click "Generate Referral Letter with AI" to auto-fill this section.