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NAME_________________________________ HOSPITAL NO. _________________________ RACE _________________________________ DATE/TIME OF BIRTH ___________________ DATE/TIME OF EXAM ___________________ AGE WHEN EXAMINED _________________ APGAR SCORE: 1 MINUTE _____________ 5 MINUTES ____________ 10 MINUTES______________ NEUROMUSCULAR MATURITY
NEUROMUSCULAR MATURITY SIGN
SEX ____________________________________ BIRTH WEIGHT __________________________ LENGTH ________________________________ HEAD CIRC. _____________________________ EXAMINER _____________________________
SCORE
-1 0 1 2 3 4 5
SCORE
Neuromuscular ______ Physical _____________ Total ________________
>90
90
60
45
30
-10 -5
ARM RECOIL
180 140 180 110 140 90 110
<90
0 5
POPLITEAL ANGLE 180 SCARF SIGN 160 140 120 100 90 <90
10 15 20
HEEL TO EAR
25
30 35 40
PHYSICAL MATURITY
PHYSICAL MATURITY SIGN
SCORE
-1 sticky friable transparent none 0 1 2 3 cracking pale areas rare veins bald areas 4 parchment deep cracking no vessels mostly bald 5 leathery cracked wrinkled
45 50
SKIN
gelatinous superficial smooth pink red peeling & / or visible veins translucent rash, few veins sparse abundant thinning anterior transverse crease only
GESTATIONAL AGE
(weeks) By dates_____________ By ultrasound________ By exam_____________
LANUGO
heel-toe PLANTAR SURFACE 4050 mm: -1 < 40 mm: -2 BREAST imperceptible lids fused loosely: -1 tightly: -2
>50 mm no crease barely perceptible lids open pinna flat stays folded
faint red marks flat areola no bud sl. curved pinna; soft; slow recoil
stippled areola raised areola full areola 12 mm bud 34 mm bud 510 mm bud
well-curved formed & firm thick cartilage pinna; soft but instant recoil ear stiff ready recoil
EYE / EAR
GENITALS
(Male)
testes in scrotum flat, scrotum empty upper canal smooth faint rugae rare rugae clitoris prominent & labia flat prominent clitoris & small labia minora
prominent clitoris & enlarging minora
GENITALS
(Female)
majora & majora majora large minora equally cover clitoris minora small prominent & minora
Reference Ballard JL, Khoury JC, Wedig K, et al: New Ballard Score, expanded to include extremely premature infants. J Pediatr 1991; 119:417423. Reprinted by permission of Dr Ballard and MosbyYear Book, Inc.