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648 North Pointe Drive Twin Falls, ID 83301

www.blueflagproject.com

(208) 731-8868

Doc Talk Worksheet



Talking to your doctor about sensitive subjects is difficult. Anxiety, fear, and even denial can creep in and make the
time you spend with the doctor unproductive. Dont assume that doctors will ask everything they need to ask at a wellness
visit. Use this worksheet to guide you through discussion with your nurse and pediatrician. If you just cant talk about it, hand
it to them and just ask them to read it. Do whatever it takes to get this information to your doctor.
Doc, I am concerned about my babys development because of the information I have discovered with the following
resources.
Specifically, I noticed:
Keep first page the same
Change to the following:

I also gave copies of the Milestone Checklists and the Blue Flag Checklist to: ____________ and ____________ just
to see if they were noticing the same things I was and their sheets are attached. I didnt coach or compare answers, I just
asked them to fill it out for me.
Finally, I filled out the ASQ-3 and MCHAT-R for additional information and got the following scores:
ASQ-3 MCHAT-R _______
Communication: _______ Cutoff = 16.81
0-2 Low Risk
Gross Motor: _______ Cutoff = 37.91
3-7 Medium Risk
Fine Motor: _______ Cutoff = 31.98
8-20 High Risk
Problem Solving: _______ Cutoff = 30.51
Personal-Social: _______ Cutoff = 26.43
The originals are attached with the follow-up questionnaires.
Based on these findings, I would like to discuss your thoughts on getting my child evaluated for Autism or other possible
developmental delays.
Do you think my child should be tested further? If not, why not?

Who can you refer me to for an Autism assessment?


Developmental Pediatrician: ____________________ Phone: _______________
Neurologist: ____________________
Phone: _______________
Psychologist: ____________________
Phone: _______________
Psychiatrist: ________________ Phone: _______________
What about these other assessments:
o
Hearing
Audiologist: _____________________
o
Cognitive
Psychologist: ____________________
o
Neurological Doctor: ____________________________
o
Speech
Speech Pathologist: ____________________
o
Sensorimotor Occupational Therapist: _________________
Is there anything else you recommend I do in the mean time?

Phone: _______________
Phone: _______________
Phone: _______________
Phone: _______________
Phone: _______________

648 North Pointe Drive Twin Falls, ID 83301

www.blueflagproject.com

(208) 731-8868

Doc Talk Worksheet


Cognitive

Communication

Social & Emotional

Physical

Blue Flags

Because of these discoveries, I filled out the MCHAT-R screening survey and it is attached. Also attached is the survey and
the follow-up info for you to look at.

* I would also like to discuss my babys most recent developmental screening.


(Recommended at 18 and 24 months. If your child hasnt had one, ask to schedule one.)

I am also concerned becuase my child only has a vocabulary of _____ words and they are hard to understand.

Questions
Looking at the info, do you think we should get an Autism assessment done? If not, why not?

Are there any other tests we should look into then?