Newborn examination form Summary!

NEWBORN EXAMINATION FORM

I. Identification Data

• Name / Hospital No.: __________________________

• Date & Time of Birth: _________________________

• Age: __________ hours / days

• Sex: ☐ Male ☐ Female

• Mode of Delivery: ☐ NVD ☐ LSCS ☐ Instrumental

• Place of Birth: ______________________________

• Attendant / Doctor: ___________________________

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II. Maternal & Antenatal History

• Mother’s Name: ___________________________

• Gravida / Para / Abortion / Live: G__ P__ A__ L__

• Antenatal Care: ☐ Regular ☐ Irregular ☐ None

• Maternal Illness / Infection: _____________________

• Drugs / Alcohol / Smoking: _____________________

• Antenatal Investigations:

  • Blood group & Rh: ___________

  • HBsAg / VDRL / HIV: ___________

  • GDM / PIH: ___________________

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III. Intranatal History

• Onset of Labour: Spontaneous / Induced

• Duration of Labour: ______ hours

• Liquor: Clear / Meconium-stained / Bloody

• Presentation: _____________________

• APGAR Score:

  Time	Score
  1 min	___ /10
  5 min	___ /10
  10 min	___ /10

• Resuscitation Required: ☐ Yes ☐ No
  If yes, specify: ________________________________

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IV. Postnatal / Feeding History

• Cried Immediately After Birth: ☐ Yes ☐ No

• Breastfeeding Initiated: Within ___ hrs

• Type of Feeding: ☐ Exclusive BF ☐ Top-up ☐ Formula

• Urine Passed: ☐ Yes ☐ No — Time: _______

• Meconium Passed: ☐ Yes ☐ No — Time: _______

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V. Anthropometric Measurements

Parameter	Measurement	Reference Range
Weight	______ kg	2.5–4.0 kg
Length	______ cm	48–52 cm
Head Circumference	______ cm	33–35 cm
Chest Circumference	______ cm	30–33 cm
Mid-Upper Arm Circumference	______ cm	—

Gestational Age (by Ballard Score): ______ weeks
Classification: ☐ Term ☐ Preterm ☐ Post-term
Weight for GA: ☐ AGA ☐ SGA ☐ LGA

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VI. General Examination

• Activity / Cry: ____________________________

• Color: Pink / Cyanosed / Pale / Jaundiced

• Posture: _________________________________

• Tone: Normal / Hypotonic / Hypertonic

• Skin: Vernix / Lanugo / Rash / Petechiae / Birthmarks

• Head & Scalp: Molding / Caput / Cephalhematoma

• Fontanelles:

  • Anterior: ☐ Open ☐ Bulging ☐ Sunken

  • Posterior: ☐ Open ☐ Closed

• Face / Eyes / Ears / Nose: Red reflex ☐ Present ☐ Absent

• Mouth: Palate intact / Cleft / Tongue tie

• Neck: Swelling / Webbing / Clavicle fracture

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VII. Systemic Examination

1. Cardiovascular System

• HR: ____ /min

• Heart sounds: S1, S2 ☐ Normal ☐ Murmur (describe)

• Pulses: ☐ Equal ☐ Delayed femoral

2. Respiratory System

• RR: ____ /min

• Chest movement: Symmetrical / Asymmetrical

• Breath sounds: ☐ Clear ☐ Added sounds

• Retractions / Grunting / Nasal flaring

3. Abdomen

• Umbilical cord: Clean / Red / Oozing

• Liver: ___ cm below costal margin

• Spleen: ___ cm

• Mass / Distension / Hernia

4. Genitourinary System

• Genitalia: ☐ Normal ☐ Ambiguous

• Testes descended: ☐ Yes ☐ No

• Anus: ☐ Patent ☐ Imperforate

5. Musculoskeletal System

• Limbs: Normal / Deformity / Fracture

• Hips: ☐ Stable ☐ Click ☐ Dislocated

• Spine: ☐ Normal ☐ Dimple ☐ Tuft of hair ☐ Swelling

6. Nervous System

• Tone: Normal / Hypotonia / Hypertonia

• Reflexes:

  • Moro ☐ Present ☐ Absent

  • Rooting ☐ Present ☐ Absent

  • Sucking ☐ Present ☐ Absent

  • Grasp ☐ Present ☐ Absent

• Seizures / Abnormal movements: _____________

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VIII. Screening & Investigations

• Blood group & Rh: __________

• TSB: __________ mg/dL

• Blood glucose: __________ mg/dL

• Screening tests:

  • Congenital hypothyroidism ☐ Done ☐ Pending

  • Hearing screen ☐ Done ☐ Pending

  • CCHD pulse oximetry ☐ Done ☐ Pending

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IX. Assessment & Plan

• Summary: ______________________________

• Diagnosis: ______________________________

• Plan / Advice:

  • Exclusive breastfeeding

  • Cord care

  • Temperature maintenance

  • Immunization: BCG / OPV-0 / Hep B

  • Follow-up: _____________________

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Examined by: _______________________
Designation: _______________________
Date / Time: ________________________