NEWBORN ASSESSMENT FORM

Name: _________________________________ Gender: ___________ Date of Birth: _________

Time of Birth: _________
VITAL SIGNS
Temperature: ______________ RR: _____________ HR: ____________

VITAL STATISTICS
Weight: __________________ Head Circumference: _______________________
Length: __________________ Chest Circumference: _______________________
Abdominal Circumference: ___________________

GENERAL
Sleep State: ( ) Alert ( ) Crying ( ) Asleep
Skin Color: ( ) Pink ( ) Cyanotic ( ) Jaundice
Skin Rashes: ( ) No ( ) Yes, describe: ____________________
Birthmarks: ( ) No ( ) Yes, describe: ____________________

HEAD
( ) Symmetrical ( ) Asymmetrical
( ) Cephalhematoma ( ) Caput ( ) Molding

EYES
( ) Symmetrical ( ) Asymmetrical
( ) Conjunctivitis ( ) Discharges

EARS
Aligned with outer cantus: ( ) Yes ( ) No
Discharges: ( ) No ( ) Yes, describe: _______________

Nose:
( ) Symmetrical ( ) Asymmetrical
( ) Patent ( ) Flaring

Mouth:
( ) Cleft Lip ( ) Cleft Palate ( ) Tongue Tie

CHEST
( ) Symmetrical ( ) Asymmetrical
( ) Clear Breath Sounds ( ) Murmurs
( ) Accessory Nipple

ABDOMEN
( ) Symmetrical ( ) Asymmetrical
( ) Protruding than the chest ( ) Flat abdomen ( ) Masses/Hernias

CORD/CORD CLAMP
( ) Dry and intact ( ) Red with Discharges ( ) Red with Foul Smell
GENITALS AND ANUS
( ) Normal Genitals ( ) Abnormal/Deformed
( ) Normal Anus ( ) Imperforated Anus

TRUNK AND SPINE

( ) Normal ( ) Spina Bifida ( ) Posterior encephalocele
( ) Deformity ( ) Masses/Lumps

EXTERMITIES
Deformities in the Arm: ( ) No ( ) Yes, describe: ____________________
Deformities in the Legs: ( ) No ( ) Yes, describe: ____________________
Complete Number of Fingers: ( ) Yes ( ) No
( ) Cyanosis
( ) Edema

APGAR SCALE
Heart Rate ( )0 ( )1 ( )2
Respiratory Effort ( )0 ( )1 ( )2
Muscle Tone ( )0 ( )1 ( )2
Reflex Irritability ( )0 ( )1 ( )2
Color ( )0 ( )1 ( )2

Assessment done by:

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