OT Neonatal Screening Form:

Child’s name: Mother’s name:

Contact number: Ward:

Gestational Age: Chronological Age:

Corrected Age:

Birth Weight: AGPAR score:

Medical conditions currently experienced: _______________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

General Appearance:

Skin colour and texture:

Normal Rashes Lesions/wounds Blue Jaundiced

(pink)

Physical Activity

Tracking Purposeful Grasp Head turn Bilateral

movements movements
Y  N Mid-range  Y  N Touch: Bilateral 
Smooth  Y  N
Purposeful  Unilateral
Sound:
Jerky  Y  N
Weak 
Movements
away from
midline

Tone

Low (floppy) Normal High (MAS 2- Severe (MAS

3) 4)

Posture

Supine Prone
Alignment: Symmetrical  Asymmetrical  Alignment: Symmetrical  Asymmetrical 
Limbs in flexion  extension  Head moves to side: Y N
Neck Extension Y N
Level of consciousness

State: How often:

State 1: Deep/Quiet Sleep

State 2: Light/ Active Sleep
State 3: Drowsiness
State 4: Quiet awake/Alert
State 5: Active Awake/ Alert
State 6: Crying

Breathing:

Regular 

Irregular 

Sensory Processing:

Able to self-comfort Y  N 

Normal sleep-wake cycle Y  N 

Hands on face/ mouth Y  N 

Relaxed movements Y  N 

Looks at mother Y  N 

Irritable Y  N 

Delayed bonding Y  N 

Fussing Y  N 

Looks away Y  N 

Extensor behaviours Y  N 

Finger/ toe splaying Y  N 

Reflexes:

Suck Y  N 

Root Y  N 

Moro Y  N 

Grasp Y  N 