Pediatric Checklist Template

A pediatric checklist is a structured form clinicians use to document a child’s health at each well-child visit in one standardized record. It covers growth, vital signs, the physical exam, developmental milestones, behavioral screening, immunizations, and safeguarding concerns. Working from the same list every visit means no assessment area gets skipped, from the newborn period through adolescence.

Behavioral screening is where most of the scoring happens. Practices pair the checklist with validated parent questionnaires. The main ones are the Pediatric Symptom Checklist (PSC-35), its 17-item short form (PSC-17), and the Preschool Pediatric Symptom Checklist (PPSC). Milestones are usually tracked against the CDC’s developmental milestones, and consistent records also support EPSDT well-child documentation for Medicaid-eligible children.

Below you’ll find a free, printable visit checklist and the scoring cutoffs for each symptom checklist by age. A step-by-step workflow shows how to run screening in your practice.

Key takeaways

A pediatric checklist records growth, vital signs, the physical exam, milestones, behavioral screening, immunizations, and safeguarding in one standardized record.

The PSC-35 and PSC-17 screen children aged 4-16, and the 18-item PPSC covers 18 months to 5 years.

Each instrument has its own cutoff: PSC-35 28 or higher (24 at ages 4-5), PSC-17 15 or higher, and PPSC 9 or higher.

A positive screen triggers further evaluation and a documented referral, never a diagnosis on its own.

Digital forms in Pabau let parents complete screening questionnaires before the visit, with answers stored in the patient record.

What goes into a pediatric checklist, and why practices use one

A pediatric checklist does two jobs. It standardizes how routine well-child findings are recorded, and it builds screening for behavioral, emotional, and developmental concerns into every visit. A complete checklist captures:

• Growth measurements: weight, height, and head circumference plotted against WHO or CDC growth charts
• Vital signs: heart rate, respiratory rate, blood pressure, and temperature
• Physical examination findings: a head-to-toe assessment by organ system
• Developmental milestones: age-appropriate motor, language, social/emotional, and cognitive skills
• Behavioral/emotional screening: validated instruments (PSC-35, PSC-17, PPSC) that identify psychosocial risk
• Safeguarding assessment: signs of abuse, neglect, or household risk factors
• Immunization and preventive care status: vaccination history and age-appropriate preventive counseling

Growth values mean little until they are plotted, so many practices keep a pediatric growth chart alongside the checklist. Percentile shifts between visits are often the first sign that a child needs a closer look.

Regulatory and payer rules drive much of this structure. In the United States, EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) requires comprehensive developmental and behavioral screening for Medicaid-eligible children.

The AAP/Bright Futures periodicity schedule calls for developmental surveillance and a psychosocial/behavioral assessment at every well-child visit. Standardized developmental screening is scheduled at 9, 18, and 30 months, and autism screening at 18 and 24 months. A structured checklist shows these steps happened and records the result in the chart.

Choosing the right tool for each age

Pediatric clinicians draw on several checklist types. Each one serves a distinct purpose and age band, and only the symptom checklists produce a validated score.

The validated instruments are free to obtain. The PSC is free and in the public domain, owned by Massachusetts General Hospital. The PPSC is free to use as part of the Survey of Well-being of Young Children, developed at Tufts Medical Center. Use them word for word, because rewording items or changing cutoffs breaks the validation.

PSC-35: how the full Pediatric Symptom Checklist is scored

The Pediatric Symptom Checklist (PSC-35) is a 35-item, parent-completed behavioral and emotional screening instrument for children aged 4-16. It is free to use and widely adopted in pediatric primary care, mental health services, and school-based health programs.

How it works: parents rate 35 statements about their child on a three-point scale: Never (0), Sometimes (1), or Often (2). Totals range from 0 to 70. A score of 28 or higher for ages 6-16, or 24 or higher for ages 4-5, indicates psychosocial impairment and warrants further evaluation.

Scores below the cutoff suggest the child is functioning within typical limits. A positive screen is not a diagnosis. It signals that further assessment is needed.

PSC-17: the 17-item short form

The PSC-17 is a 17-item version of the PSC-35 for the same age range (4-16 years), built for busy primary care visits. It uses the same 0-2 scoring and groups items into three subscales:

• Internalizing: anxious, depressed, or withdrawn symptoms
• Externalizing: aggressive, disruptive, or rule-breaking behavior
• Attention problems: difficulty with concentration, task completion, and impulse control

A total of 15 or higher is a positive screen. The published subscale cutoffs differ by domain: Internalizing 5 or higher, Attention 7 or higher, and Externalizing 7 or higher. Subscale scores show which domain needs follow-up. The PSC-17 takes 2-3 minutes to complete, compared with 5-10 minutes for the PSC-35.

PPSC: behavioral screening from 18 months to 5 years

The Preschool Pediatric Symptom Checklist (PPSC) is an 18-item parent questionnaire for children aged 18 months to 5 years. It was developed by Sheldrick and colleagues at Tufts, building on the PSC. It captures behavioral and emotional concerns in the preschool years, when early intervention is most effective.

Parents answer each item Not at all (0), Somewhat (1), or Very much (2), for a total of 0 to 36. A total of 9 or higher flags a child “at risk” for further evaluation. Practices use the PPSC at well-child visits, preschool health screenings, and early intervention intake.

Each instrument has its own age band and cutoff. The chart below lines all three up, so you can pick the right form before the visit.

Head-to-toe physical exam items

A physical exam checklist walks the clinician through the examination from head to toe, so no system is overlooked. A complete pediatric exam includes:

• General appearance: alert, distressed, well-nourished, dysmorphic features
• Vital signs: temperature, heart rate, respiratory rate, blood pressure
• Head and neck: hair, scalp, anterior fontanelle (infants), eyes, ears, nose, throat, neck lymph nodes, thyroid
• Cardiovascular: heart rate, rhythm, heart sounds, murmurs, femoral pulses
• Lungs: breathing pattern, breath sounds, accessory muscle use, signs of respiratory distress
• Abdomen: distension, tenderness, organomegaly, bowel sounds
• Genitourinary: external genitalia, inguinal nodes
• Musculoskeletal: spine, joints, range of motion, gait
• Neurological: mental status, cranial nerves, motor tone, reflexes, developmental assessment
• Skin: color, texture, rashes, lesions, birthmarks

Age-specific items include fontanelle assessment and hip dysplasia screening in infants, and pubertal development in adolescents. For the full exam sequence and what changes at each age, see our guide to the pediatric physical examination.

Developmental milestones by age

The CDC’s “Learn the Signs. Act Early.” program publishes evidence-based milestones across four domains: social/emotional, language/communication, cognitive, and movement/physical development. A milestones section lets clinicians record which skills a child has reached and which need follow-up.

Clinicians use this framework at each well-child visit to check for typical development. When a child is not meeting age-expected milestones, further evaluation may be warranted. Referral goes to early intervention for children under 3, or to special education services (age 3 and older).

Where the checklist fits in a well-child visit

Screening works best when each step has an owner, from the pre-visit form to the referral note:

1. Pre-visit administration. Send behavioral screening forms (PSC-17 or PPSC, by age) to parents 1-2 days before the appointment, digitally or on paper. Answers are then ready when the clinician walks in.
2. Clinical assessment. During the visit, the clinician completes the physical exam, documents milestones, and reviews the parent’s screening form.
3. Scoring and interpretation. Total the PSC or PPSC and compare it with the cutoff for the child’s age. For a positive screen, document the finding and next steps, such as a referral for behavioral health evaluation.
4. Documentation. Save the completed checklist in the patient record with the date, scores, and clinician signature. Include any action items or follow-up plans the result triggered.
5. Follow-up. For positive screens, arrange timely referral and follow-up per your practice protocol. Document the referral and its outcome in the medical record.

Digitizing the checklist reduces transcription errors, flags blank sections before the form is submitted, and leaves an audit trail for quality reviews.

How Pabau gets screening forms completed before the visit

On paper, the PSC-17 gets handed over in the waiting room, scored by hand, and scanned into the chart later. Pediatric visits are short, so a form finished during the visit eats into exam time.

Pabau, the practice management platform we build, turns the checklist and screening questionnaires into digital intake forms. Automated workflows send the right form to parents ahead of the appointment. Completed answers land in the child’s record, dated and ready for the clinician to review.

The clinician opens the child’s medical records with the parent’s responses already there, then scores and documents the result in the same place. The same system handles scheduling, billing, and charting, which is why family and pediatric practices run it as their primary care software. Stored, signed checklists support documentation for EPSDT and AAP recommendations.

Get screening forms back before the visit

Pabau sends pediatric checklists and screening questionnaires to parents before the appointment and stores their answers in the patient record. That leaves the visit for examining the child.

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Conclusion

A checklist only pays off when the screening behind it is scored correctly. Match the instrument to the child’s age, apply that instrument’s own cutoff, and treat every positive result as a reason to evaluate, not a diagnosis.

Start with the downloadable checklist for the visit itself, then add the PSC-17 or PPSC as a pre-visit form. The trade-off is setup time now for shorter, better-documented visits later. Book a demo to see how Pabau gets parent screening forms completed and filed before the child arrives.

Continue your research

Want the full assessment framework? Pediatric assessment walks through history, observation, and exam findings by age.

Need a structured symptom review? Pediatric review of systems template gives you a system-by-system checklist to pair with the exam.

Unsure what counts as normal vitals? Pediatric vital signs chart lists expected heart rate, breathing rate, and blood pressure ranges by age.

Tracking vaccines at each visit? Immunization record form keeps doses, dates, and catch-up needs in one place.

Screening for sleep problems too? Pediatric sleep questionnaire helps you flag sleep-disordered breathing and poor sleep habits.

Frequently asked questions