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Newborn Screening Continuity Clinic Initial Consult Form

NCR/MIMAROPA

Name of Patient: _________________ _______________ _____ Date: ____________________


Family Name First Name No. of Consult: ____________
MI
Date of Birth: _____________ Age: ______ Sex: _______ Case Number: _____________
Location: OPD Pay Ward Type of Patient: New Old
Address:__________________________________________________________________________
_______________________________________________________ Region: ___________

Contact Person/s: _________________ Tel.: ________________ Mobile No: __________________


Mothers Name: _________________________ Fathers Name: _________________________
Referring Doctor: ________________________ Service: ________________________

Weight ___________ ( )
Height ___________ ( )
HC ______________ ( )
CR __________ RR __________
BP __________ Temp _________

HISTORY OF PRESENT ILLNESS:

BIRTH AND MATERNAL HISTORY:

Birth weight: ________ _____ y/o G____ P___ delivered at ____________ c/o _______________

( ) PNCU ( ) Diabetes ( ) Fever


( ) Fetal Movements ( ) Hypertension ( ) exposure to viral infection
( ) Ultrasound ( ) Smoking ( ) Infection
( ) Oligohydramnios ( ) Alcohol ( ) Antibiotics
( ) Polyhydramnios ( ) Abortifacients ( ) Drugs _____________
( )Exposure to radiation ( ) Skin Rash ( ) Others, pls. specify ____________
PAST MEDICAL HISTORY:

FAMILY HISTORY:

NUTRITIONAL HISTORY:

DEVELOPMENTAL HISTORY:

PERSONAL AND SOCIAL HISTORY:


Socioeconomic status
Maternal Age/education attained:
Paternal Age/education attained:

IMMUNIZATION HISTORY:

PHYSICAL EXAMINATION:

Head and Neck:

Chest/Cardiac:

Lungs:

Abdomen:

Genitalia:
Upper Extremities:

Lower Extremities:

Neurologic exams:

Skin:

Investigations done:

SUMMARY:

IMPRESSION:

PLAN:

___________________________________
M.D.

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