SAN PEDRO COLLEGE

Davao City
NURSING DEPARTMENT

ASSESSMENT GUIDE
(INFANT)
Personal Data
Name of Patient: ___________________________ Birthday: _________________ Age: _______ Ordinal Rank: ___ of ___ siblings
Address: _____________________________________ Nationality: __________________ Religion: ________________________
Name of Father: ________________________ Age: _____ Educational Attainment: ________________ Occupation: __________
Name of Mother: _______________________ Age: _____ Educational Attainment: ________________ Occupation: __________

ADMINISTER MMDST

ASSESS / INTERVIEW
A. MATERNAL/OBSTETRICS/PRE-NATAL HISTORY: AOG: ____ G ___ P ___ T ___ P __ A __ L __
Prenatal Check-ups: ____________________________________ Complications during pregnancy: _________________________
TT Vaccines (include dates): __________________________________ Medications taken during pregnancy: _________________
Labor & Delivery: ____________________ No. of hours of labor: ____________________ Use of Anesthesia: ________________
B. BIRTH HISTORY:
Manner of delivery: NSVD CS Instrumentation __ Place: Home Hosp. _____ Lying-in _______
Presentation: __________ Birth Weight: _____ Birth Height: _____ Other Measurements (in cms): HC: ____ CC: _____ AC: ______
C. NEONATAL
The child underwent newborn screening: _______________________________ Length of Stay in Hospital: __________________
Complications: ________________________________________________ Medications: _________________________________
D. INFANCY & CHILDHOOD
Childhood Diseases: Mumps Chicken pox Polio Measles Pneumonia Hepatitis Asthma Diphtheria
Others (pls. specify) _________________________________________________________________________________
Immunizations: BCG HepB OPV DPT Measles HiB HepA Meningitis TT Others (pls. specify) ___________
Allergies: ________________________________________ Congenital Problems: _______________________________________
Previous Hospitalizations (Why, Where, Treatment, Outcome): ______________________________________________________
Serious Injuries: (Fractures, head injuries with loss of consciousness, motor vehicle accidents, burns, or lacerations) ____________
Medications: ______________________________________________________________________________________________
E: NUTRITION
Breastfeed: Frequency: ______ (by demand or every ___ hours) Sucking strength: __________ Problems: __________________
Bottlefeed: Formula Milk: _________ Dilution: ________ Frequency: ______________ Problems: ________________________
Food preferences: _________________________________ Meal Patterns & Appetite: ___________________________________
Feeding Problems: __________________________________ Vitamins/Minerals/Food Supplements: _______________________
Dentition: Age of onset: _____ S/sx of teething: _____________________ Number of Teeth: _____ Specify Teeth: ____________
F: ELIMINATION
Pattern: BM/day: ________________ Consistency: _________ Amount: _______ Color: _________ Urination/ day: ____________
Problems: Constipation Diarrhea Others: __________________________________________________________________
G: ACTIVITY & SLEEP
Usual Sleeping Patterns: __________ No. of Hrs: _______ Naps: _______ Rituals: ______ Problems: ________________________
Usual Daily Activities: ________________ Plays: ______________________ Toys: _______________________________________
H. GROWTH & DEVELOPMENT
Physical Development
Anthropometric Measurements Ht: _______ HC: ________ CC: ________ AC: ________
Cephalocaudal Appearance
Personal hygiene
Reflexes

Language Development
Language/ Dialects
Words uttered
(Please include other observation in terms of language development not included as part of MMDST)