Pediatric ASD Early Screening Checklist
Child Information
Child's Name
Date of Birth
Parent/Guardian Name
Physician Name
Screening Date
Screening Checklist
Limited eye contact
Does not respond to their name
Delayed speech or language skills
Lack of gestures (pointing, waving)
Repetitive movements or behaviors
Does not share interests or emotions
Unusual reactions to sound, light, or textures
Difficulty with transitions or change
Plays alone more than with others
Infrequent smiling or social responsiveness
Comments/Observations