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BIO DATA: NAME: AGE: SEX: DATE OF ADMISSION: DATE OF DISCHARGE:-OPD NUMBER: IPD NUMBER: BIRTH DATE: BLOOD GROUP: ADDRESS: DR: UNIT: RELIGION: NATIONALITY: FATHER: MOTHER: FAMILY INCOME: FOOD TYPE: HABITS: YEAR/MONTH: WARD:
HISTORY Birth history Diet history Personal history Socio economic status
ANTHROPOMETRIC MEASUREMENTS Biological Measurement: No 1 2 3 4 5 6 Measurement Height Weight Head circumference Chest circumference Arm circumference Vital sign : Temp Child value Normal value Remark
Pulse Respiration B.P Percentage of malnutrition: actual weight100/ideal weight : : PEM GRADE: DEVELOPMENTAL HISTORY
NORMAL OBSERVATION Gross motor : Fine motor: Psychological: Psychosexual: Spiritual: Intellectual or cognitive Moral: LANGUAGE: Receptive language:
CHILDS OBSERVATION
INFERENCE
Expressive language: Play stimulation: EXAMINATION OF THE CHILD: General appearance Nourishment: Body Build
1. Skin Color: Texture: Lesions: Temperature: Birthmarks 2. Head Size: Shape: Hairs: Distribution: Color: Texture: 3. Scalp Fontanel: Hair: 4. Face: Eyes: Location: Eyebrows: Eyelids: Eyeballs: Conjunctiva: Sclera: Pupil: Reaction to light: Ears: Location: Hearing: Discharge: Nose: External nares: Nostril: Mouth and Pharynx: Lips:
Odor from the mouth: Teeth: Tongue: Mucus membrane: Throat and pharynx: 5. Neck: Skin folds: Lymph node: 6. Chest: Size: Shape: Breath sounds: Respiratory rate: Respiratory rhythm: 4. Heart: Heart Sound: Heart Rate: 5. Abdomen: Distension: Palpable Mass: Bowel Sounds: 6. Umbilical cord Number of vessels at birth Appearance 7. Extrimities: A.Hands: Length Movements Muscle tone Fingers B.Legs: Appearance Length Movement Alignment Muscle tone Toes Number
Webbing Position 8. Nails: Clubbing: Flattened: Capillary Refilling: 9. Back 10. Genital FEMALE 1. Labia Size Appearance 2. Vaginal discharge (In Pre Term) Color Type MALES Testes in scrotum Urethral meatus at end of penis Circumcised VOIDINGS Amount Frequency 11. Rectum: a. Patency b. Stools 1. Color 2. Consistency 3. Frequency