Free ASD Screening Form for Children Age 2–6

Child Information

Child's Full Name *

Parent / Guardian Phone Number *

Parent / Guardian Email Address *

Date of Birth

Current Age — Years

Current Age — Months

Gender

Date of Form Completion

Person Completing Form *

Relationship to Child

Any known medical conditions / previous diagnoses

1 Birth & Early History

Did the child cry immediately after birth?

Don't remember Delayed cry No Yes

Birth weight

Gestational age (weeks)

Any complications during birth or pregnancy?

No Yes

Was the child in NICU / special care?

No Yes

Duration (if applicable)

2 Vaccination History

Please indicate all vaccines the child has received (or mark completed according to schedule).

Vaccine	Given?	Age When Given	Any Reaction?	Comments
BCG
Hepatitis B
OPV / IPV (Polio)
DTP / DTaP / Pentavalent
Hib
Rotavirus
PCV (Pneumococcal)
MMR
Varicella (Chickenpox)
Hepatitis A
Typhoid
Influenza
COVID-19 (if applicable)
Any other

Any unusual reactions after vaccines (overall)?

No Yes

3 General Health & Illness Frequency

How often does the child fall ill?

Rarely (1–2 times a year) Occasionally (3–5 times a year) Frequently (every 1–2 months) Very frequently (almost every month or more)

Common illnesses the child gets

Stomach infection Ear infection Fever Cold / Cough Allergies Skin issues

Average body temperature when well

Often runs fever without clear reason?

No Sometimes Yes

Any history of seizures / fits?

No Yes

4 Gut Health, Digestion & Toilet Habits

How is the child's overall gut health?

Poor Average Good

Digestion issues (tick all that apply)

Frequent constipation Frequent loose stools / diarrhoea Alternating constipation & diarrhoea Bloating / gas Stomach pain Acid reflux / vomiting Food intolerances / allergies None

Stool consistency most of the time

Very watery Loose Soft Normal Hard

How often does the child pass stool?

Multiple times a day Less than twice a week Every 2–3 days Daily

Any unusual smell, colour, or mucus in stool?

No Yes

Toilet / Potty Training

Does the child have accidents (urine or stool) during the day or night?

No Sometimes Yes

Skill	Age Started	Current Status	Comments
Started potty training
Urine independently on toilet
Pooping independently on toilet
Staying dry during day
Staying dry at night
Cleaning self after toilet
Washing hands after toilet

5 Self-Care & Daily Living Skills (Current Level)

Rating scale: 1 = Cannot do / Fully dependent · 2 = Needs a lot of help · 3 = Needs some help / reminders · 4 = Mostly independent · 5 = Fully independent

Activity	Rating (1–5)	Comments
Brushing teeth
Washing face
Bathing / showering
Dressing (clothes)
Putting on shoes
Eating with spoon/fork
Drinking from open cup
Cleaning up toys
Putting dirty clothes away
Following morning routine
Following bedtime routine

6 Social Interaction & Communication

Options: Always / Often / Sometimes / Rarely / Never

Item	Always	Often	Sometimes	Rarely	Never
Makes eye contact during interaction
Responds when name is called
Points to show interest
Shares enjoyment with others
Shows interest in other children
Uses gestures (pointing, waving)
Starts conversations or shares experiences
Understands simple instructions
Uses appropriate facial expressions
Prefers playing alone

7 Play, Interests & Sensory Behaviours

Engages in pretend / imaginative play

Never Rarely Sometimes Often Always

Has very intense or restricted interests

No Somewhat Yes

Strong reactions to sounds, lights, textures, smells or tastes

No Sometimes Yes

Repetitive body movements (hand-flapping, rocking, spinning, toe-walking)

No Sometimes Yes

Distressed by small changes in routine

No Sometimes Yes

Lines up toys or objects

No Sometimes Yes

8 Emotional Regulation & Behaviour

Frequent meltdowns or extreme reactions

No Sometimes Yes

Difficulty calming down after becoming upset

No Sometimes Yes

Sleep difficulties

No Sometimes Yes

Extremely picky eating / limited food range

No Sometimes Yes

9 Additional Notes

Any other important observations, strengths, or concerns

Family history of autism, ADHD, developmental delays, gut issues, or related conditions?

No Yes

📋 Summary for Doctor / Specialist

Please discuss this completed form with your child's doctor. If multiple areas of concern are present (especially social communication + repetitive behaviours + sensory or gut issues), a full developmental assessment is recommended.

Main health concerns

Main developmental / behavioural concerns

Areas needing urgent attention

Comprehensive Autism Screening & Developmental Observation Form

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