1. Developmental Screen – 3.0 – 4;11 years (score Y=1; N=0)
Insert Patient sticker here
Child’s age: ……. Years………Months
Date of assessment: ____/___/_____
1. Gross motor skills (score 0-4) Achieved
Age (yrs;months)
Gross motor score
3;0-3;5
1-4
3;6-3;11
2-4 1
4;0-4;5
3-4 2
4;6-4;11 4 3
0-2
Throws a ball and walks to retrieve it
Y / N
Up one foot per step, down two feet per step
Hops on one foot without holding on
Goes up and down stairs one foot/step at a time
Total /4
2. Fine motor skills (score 0-4) Achieved
Age (yrs;months)
Fine motor score
3;0-3;5
1-4
3;6-3;11
2-4 1
4;0-4;5
3-4 2
4;6-4;11 4 3
0-2
Copies a circle
Y / N
Folds a piece of paper in half
Draws a recognisable man
Draws a house
Total /4
3. Daily living skills (score 0-4) Achieved
Age (yrs;months)
Daily living score
3;0-3;5
1-4
3;6-3;11
2-4 1
4;0-4;5
3-4 2
4;6-4;11 4 3
0-2
Uses spoon and fork
Y / N
Dresses & undresses self, and does buttons
Washes and dries hands and face
Puts shoes on correct feet
Total /4
4. Communication (score 0-4) Achieved
Age (yrs;months)
Communication score
3;0-3;5
1-4
3;6-3;11
2-4 1
4;0-4;5
3-4 2
4;6-4;11 4 3
0-2
Counts to 4
Y / N
Repeats 4 numbers
Talks in sentences of 6+ syllables
Asks questions about meaning of words
Total /4
5. Socialisation (score 0-4) Achieved
Age (yrs;months)
Socialisation score
3;0-3;5
1-4
3;6-3;11
2-4 1
4;0-4;5
3-4 2
4;6-4;11 4 3
0-2
Engages in pretend play
Y / N
Imaginary companion
Understands taking turns
Domestic role play
Total /4
6. General understanding (score 0-4) Achieved
Age (yrs;months)
General understanding score
3;0-3;5
1-4
3;6-3;11
2-4 1
4;0-4;5
3-4 2
4;6-4;11 4 3
0-2
Counts 4 objects correctly
Y / N
Compares two weights (which one is heavier)
Distinguishes morning from afternoon
Names 8 colours
Total /4
Does the parent have any concerns about their child?
Languages spoken at home
Child’s primary language
Copyright: Great Ormond Street Hospital for Children NHS Foundation Trust

2. Developmental Screen – 3.0 – 4;11 years, continued.
Insert Patient sticker here
Behaviour/coping skills:
Circle any problems parents report in the following areas
Internalising behaviours
Externalising behaviours
Other
Clingy or anxious
Impulsive
Overactive
Eating difficulties
Temper tantrums
Attention problems
Sleep problems
Defiant
Bed wetting
Sad or withdrawn
Physical aggression
Soiling
Phobias
Inappropriate behaviours
Peer problems
Total /15
Any known disability (including any visual or hearing problem) or non cardiac diagnosis _________________________________________________________________________
Multi disciplinary teams
Issues currently under these services
Ongoing medical treatment/Assessments
Intended Operation/Procedure __________________________________________         
Date of scheduled operation/procedure ____/___/_____
Assessment on the basis of clinical observation and/or parent report
(please tick accordingly)
Any noted observations _______________________________________________________
Action agreed if appropriate
Signature and name of Assessor
Signature and name of Parent
Copyright: Great Ormond Street Hospital for Children NHS Foundation Trust