NAME_________________ DIET ____________

TIME OF DELIVERY_______________ BABY

V______C________EPISIOTOMY: Y / N PEDIATRICIAN_________________________________

COMPLICATIONS_________________________________ MALE_____ FEMALE_________

______________________________________________
WT:_______LBS________OZ________GRAMS
G______ P_______
APGARS:______1MIN________5MIN
ALLERGIES ____________________
GESTATION:_______WKS________DAYS
BLOOD: A O B AB + - BREAST / BOTTLE / BOTH

NEED RHOGAM: Y / N FEEDING? Y / N_________________________________

RUBELLA: IMM / NON LACTATION CONSULT: Y / N

HEP B: POS / NEG PEE: Y / N POOP: Y / N

HIV: POS / NEG HEP B: Y / N

VS 0800 1200 1600 HEARING TEST: Y/ N

T BLOOD: A O B AB + -
♥
COOMBS: NEG / POS
BP PKU: Y / N
RR VS 0800 1200 1600
T
O2 ♥
RR
PAIN
LABS
B U B B L E H E
080 ______________________________________________
0 ______________________________________________
120
0 MEDS
160
0 ______________________________________________
NOTES_________________________________________ ______________________________________________
______________________________________________

MEDS:_________________________________________
______________________________________________
______________________________________________

VOIDING: Y / N IN________________

PASSING GAS: Y / N OUT_____________