Fetal Alcohol Spectrum Disorder Evaluation Form
Please complete this form to assist in the assessment of Fetal Alcohol Spectrum Disorder (FASD). All information will remain confidential.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Caregiver/Parent Name
*
First Name
Last Name
Relationship to Patient
*
Please Select
Mother
Father
Guardian
Other
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Has the patient experienced prenatal alcohol exposure?
*
Yes
No
Unknown
Developmental Milestones
*
Rows
On Time
Delayed
Not Applicable
Sitting
1
2
3
Walking
4
5
6
First Words
7
8
9
Toilet Training
10
11
12
Behavioral Observations (rate the following)
*
Rows
Never
Sometimes
Often
Always
Difficulty following instructions
13
14
15
16
Impulsivity
17
18
19
20
Attention problems
21
22
23
24
Social difficulties
25
26
27
28
Physical Features Associated with FASD (select all observed)
Smooth philtrum
Thin upper lip
Short palpebral fissures
Growth deficiency
Other (specify below)
If you selected 'Other' above, please specify:
Additional Comments or Concerns
Submit Evaluation
Should be Empty: