NEONATAL ASSESSMENT

NAME: - DOB:-

SEX: - WEIGHT:-

IPD NO: - ADDRESS:-

INFORMER OF CASE: - DATE:-

Chief complaint

HISTORY

Maternal h/o:-

Infant h/o:-

DOB: - EDD: - place of birth:-

Age at birth: - Age post birth:-

Mode of delivery: - Fetal position:-

Birth weight: - Present weight:-

Height at birth: - Present height:-

Head circumference at birth: - present H.C:-

Immediate cry: - Apgar score:-

Place of delivery: - First feeding: -

Any complication during birth:-

No of days in nicu:- Reason for admission in nicu:-

Current issue and concern:-

Immunization:-

Past history

Pre pregnancy health status:-

Previous obstetrical h/o:-

Course of pregnancy/Antenatal h/o:-

Family h/o:-

Drug h/o

Socio-economic h/o:-

Observation
Mode of feeding:-

IV-

Gavage: - nasal oral

Bottle:-

Type: - breast milk formula

Care giving interval

General alertness:-

Type of cry:- Excessive sleepiness

Single palmar crease :- Single umbilical artery:-

Hypoplasia of depressor anguli

Mid line lesion on the back and front:-

Vital signs

H.R R.R B.P

Temperature Capillary refill:-

Anthropometry

Weight Height

Head circumference Chest circumference

Upper segment/lower segment ratio:-

Gestational assessment: -New Ballard score
SYSTEMIC EXAMINATION

Skin

Skull

Face

Spine

Oral-motor function

Palpation:-

Rooting reaction:-

Gag reflex:-

Bite reaction:-

Suck-swallow pattern:-

Sucking: - non-nutritive:-

Nutritive:-

Strength: - Endurance:-
Cardio respiratory:-

Mode of ventilation: - Route of ventilation:-

O2 saturation: - cyanosis:- Oedema:-

shape and symmetry of chest:- Periodic breathing pattern:-

Auscultation:-

Silverman index:

FEATURE SCORE 0 SCORE 1 SCORE 2

Chest Equal Respiratory Seesaw

Movement Lag Respiration

Intercostal None Minimal Marked

retraction

Xiphoid None Minimal Marked

retraction

Nasal Flaring None Minimal Marked

Expiratory None Audible w/ Audible

grunt stethoscope

Total score:-
Central nervous system examination

Cranial nerves:-

Special senses:-

Motor:-

Spontaneous movement

Muscle tone

Tendon jerk

Primitive reflexes

Moro: - Glabellar tap: - Rooting and sucking:-

TNR:- Traction reflex:- Palmar and plantar grasp

Assessment of family resourses and needs

Educational level of parents

Occupation of parents

Income level

Family members

Environment history

Investigations

Management