Informant: _______________ (____% Reliability) Vitamin K Given?

__________________________
General Data:
Name: ___________________________________ Prenatal Hx:
Age: ________ Prenatal Check ups:
Sex:_________ how many times:______
Religion:______________________ where:______________________________________
Birthday:______________________ to whom:____________________________________
Address: _____________________________________ Medications/Vitamins
# of admissions: _______________________________ given:________________________________________
Present Hospital of Admission: ___________________ _____________________________________________
Date of Admission: _____________________________ Medical conditions/illnesses during
pregnancy:____________________________________
Chief Complaint:____________________________ _____________________________________________
HPI: _____________________________________________

1) Enquire as to when patient was last entirely well? Neonatal History:

2) Presenting complaints
ANTENATAL HISTORY (H/O PREGNANCY)
a) Time (onset , duration , frequency , course)
1) H & N status (Health and nutritional status of mom
b) Place (site)
during pregnancy)
c) Quality (character e.g. of pain , composition of vomitus)
2) Illness during pregnancy (HTN, DM, pre-eclampsia,
d) Quantity (severity of pain , amount of vomitus)
antepartum haemorrhage)
e) Provocative / alleviative factors / variations (diurnal or
3) Infections during pregnancy (rubella, UTIs, syphilis, T.B.)
seasonal)
4) Drugs (iron, multivitamin, other drugs with dose,
f) Associated symptoms
duration and at which time of gestation)
g) Treatment if any
5) X-ray (h/o irradiation in 1st trimester)
6) TT (maternal vaccination against tetanus)
3) Systemic inquiry
7) Past obstetric (problems with previous pregnancies,
a) General (weight loss , appetite)
stillbirths, miscarriages, birth weight of previous children,
b) CVS (shortness of breath on exertion , shortness of breath
prematurity, blood transfusions)
and sweaty on feeding, cyanotic spells, squatting,
NATAL HISTORY (H/O DELIVERY)
fainting or syncope, cyanosis, edema, chest
1) Place of delivery (hospital/home)
pain/palpitations)
2) Conducted by (dai/trained health visitor/doctor)
c) Respiratory system (sore throat, earache, cough,
3) Sterilization technique for instruments
wheeze, frequent chest infections, history of aspiration,
4) Gestation time (length)
hemoptysis)
5) Rupture time (time of rupture of membranes)
d) Gastrointestinal system (abdominal pain, vomiting,
6) Labour time (duration)
jaundice, diarrhea/constipation, blood in stools)
7) Presentation and type of delivery (SVD, forceps, vacuum
e) CNS (fits, syncope/dizziness, headache, visual problems,
extraction or C-section)
numbness/unpleasant sensations, weakness/frequent
8) Sedation/analgesics during labour
falls, incontinence)
9) Complications (abnormal bleeding)
f) Genitourinary system (stream, dysuria, frequency,
POSTNATAL HISTORY
nocturia/enuresis, incontinence, hematuria)
1) 1ST cry (immediately/cyanosed/apneic)
g) Rheumatological system (limp, joint swelling, hair loss,
2) Basic problems (need for resuscitation, problem with
skin rash, dry mouth/mouth ulcers, dry or sore eyes, cold
respiration, sucking/swallowing)
extremities)
3) Birth weight
4) Birth injury
Birth History: 5) Convulsions, cyanosis, jaundice, fever, rash
Age of Mother @ time of birth: _________years old 6) Procedures (exchange transfusion, umbilical artery
OB Score: G__P__ (__-__-__-__) catheterization, drugs)
Assisted by:___________ Presentation:__________
Mode of Delivery: NSD/CS
Place of Delivery:_________________________
Umbilical cord was cut by: ____________________
Birthweight:________________________________
Family Hx: ROS:
Father: Integumentary: [ ] pruritus
HTN:____ DM:_____ Asthma:_____ Heart dse:______ CNS: [ ] Headache [ ] Seizure
Epilepsy:_____ TB:______ Blood d/o:__________ CRS: [ ] cough [ ] colds [ ]DOB [ ]Chest pain
Mother: GIT: [ ]Vomiting [ ]abdominal pain [ ]diarrhea
HTN:____ DM:_____ Asthma:_____ Heart dse:______ [ ]constipation
Epilepsy:_____ TB:______ Blood d/o:__________ GUT: [ ]oliguria [ ]dysuria [ ]hematuria
Hematologic System: [ ] epistaxis [ ]gumbleeding
Nutritional Hx: [ ]easy bruisability
Breast fed since _____ to ______ MSS: [ ]myalgia [ ]arthralgia
Milk (brand)_____, dilution: __:__oz Endocrine: [ ]loss of appetite [ ]sweating [ ]fever
Complementary feeding when____
Table food introduced at ________ Physical Examination
Present diet_____________ Gen. Survey:
Awake/Conscious
Personal and Social Hx: Febrile/Afebrile
Order in the family:_____________________________ Weak looking
Father: name:_____________ Age:___ Occupn: _____ Cardiorespiratory Distress
Mother: name:_____________ Age:___ Occupn: _____
Type of House:________________ # of fam mem:____ Vital signs:
Source of drinking water:_________________________ Temperature:___________C
Boiled or not Heart Rate: ___________/bpm
Respiratory Rate: _______/cpm
Immunizations: BP: _____________mmHg
BCG:_____________ 1dose/s Anthropometric Measurement:
Hepa B:_____________3 dose/s Height: _________cm
DPT:_____________3 dose/s Weight:_________g/kg
OPV:_____________3 dose/s HC:____________cm
Measles:_____________1 dose/s CC:____________cm
AC: ___________cm
Growth & Development:
Smiles: ____________ months Skin:
Rolls over: ________________months Bruises:
Sits with support: ________________months Petechiae
Holds bottlle: ________________months Jaundice
Sits without support: ________________months Pallor
Says papa/mama 1st word: ________________months Cyanosis
Stands with support: ________________months Jaundice
Walks alone: : ________________months warm to touch
Feed self with spoon: : ________________years Good skin turgor
Runs well: ________________years Plethora
Enters kindergarten: ________________years Vernix caseosa
Enters elementary: ________________years Lanugo
Dry Skin
Mongolian spots
Capillary hemangiomas
Milia
Milaria
Erythema toxicum
 Heart
HEENT: Precordium (Dynamic/Adynamic)
Head: PMI: _____ICS LMCL
Distribution of hair: Murmur
Cephallohematoma o Grade:____
Caput succedaneum o Location:____
Patent fontanelles o Soft blowing/Rough
o Anterior: o Systolic/diastolic
o Posterior: o Radiating to:______
o Size:
o sunken Heartbeat
Micro/Macrocephaly: o Rate (Normal/Abnormal)
Eyes: o Rhythm (Regular/Irregular)
Subconjunctival Hemorrhages: Abdomen:
Cornea (tear/clouding) Globular/Flat
Epicanthal folds Normoactive Bowel Sounds:
Eye movements (Coordinated/uncoordinated) Soft/Tender
Sclera (Icteric/Unicteric) Organomegaly
palpebral conjunctiva (pink/pale) Abdominal distension
Ears: Abdominal masses
Discharges: Umbilical cord
Malformation (low set)
Deformities Genitalia & Anus
Nose: Male
Discharges: o mass
Size & Shape o hernia
Nasal obstruction o hydrocele
Nasal flaring o Testis (descended/undescended)
Female
Mouth: o Labia: labia majora covers minora
Epstein pearls: o discharge
Prominent tounge: o mass
Tonsillopharyngeal Congestion: Tanner Staging:
Palate
Cleft lip Extremities:
Tounge (micro/macroglossia) Edema
Oral thrush Clubbing
Ulcers in the lips Pink/pale nail beds
Pulses: full and equal pulses,
Neck: CRT 1-2 seconds
Cervical Lymphadenopathy:
Webbing of the neck
Masses:

Chest & Lungs:

Symmmetrical Chest Expansion:
Retractions
Rales
Wheezes
Neurologic Exam

MSE: awake,lethargic
GCS:
Cerebellar: px able to grasp things w/ good
coordination and w/o difficulty
CN Exam:
o CNI:____(able to smell)
o CNII:__________(pupil equally roud
responsive tolight and accomodation, 2-
3mm)
o CN III/IV/VI:___________(able to
follow moving objects at diff directions
w/o deviation)
o CN V: ______________(px smiles,able
to feel elicited stimulus)
o CN VII:_________(no facial assymetry)
o CN VIII:____________can hear
o CN IX/X: ______swallowGag Reflex
o CN XI:_______elevate w/o difficulty
o CN XII: ____________tongue deviation

Meningial Signs
o Nuchal rigidity
o Brudzinski
o Kernigs
Reflexes
o Palmar Grasp
o Babinski reflex
o Rooting Reflex
o Moro Reflex
o Tonic neck reflex
Motor: ______________grade___/___
(good motor strength,able to move extre.)
Sensory: withdraws to pain ____%
DTR:+__patellar reflex
+___biceps reflex