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Term?
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Pre-Term?
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Gestation
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Gestation +days
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APGAR 1 minute
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APGAR 5 minutes
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Baby born via NSVD
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Birth comments
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Birth Weight
• • •
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Birth Weight - Ounces
|
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birth legth
|
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Discharge Wgt
/
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% loss from BW
|
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1st peds visit weight and date
/
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Hep B Vaccine Date
|
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2nd Peds visit weight and date
/
|
Started vitamin D?
|
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3rd pediatrician visit weight and date
/
|
|
|
Hearing Screen
|
Infant Blood Type
|
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Maternal Blood Type
|
Complications Comments
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Direct Coombs
|
|
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Neonatal Complications
• • •
|
|
|
|
|
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Nutrition
• • •
|
Problems breastfeeding
• • •
|
|
Breastfeeding Hours between feed
|
breastfeeding minutes
|
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Other milk type
|
Ounces per Feeding
|
|
number of urine/bm per day
/
|
Elimination Comments
|
|
|
Feeding Hx
|
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lbs/oz
/
|
length
|
|
WHO growth percentile weight/length for age
/
|
Fenton Growth Chart
|
|
PE: Constitional
• • •
|
constition comments
|
|
Eyes
• • •
|
Head Exam comments
|
|
Suck exam
• • •
|
Eye exam comments
|
|
Neck and Shoulders
• • •
|
Mouth exam comments
|
|
Respiration
• • •
|
Suck exam comments
|
|
Abdominal
• • •
|
Resp exam comments
|
|
Extremities
• • •
|
Head and neck comments
|
|
Neuro
• • •
|
Abd exam comments
|
|
Skin
• • •
|
extremity exam comments
|
|
|
Neuro exam comment
|
|
|
skin exam comments
|
|
Development - Communicative
• • •
|
|
|
Anticip. Guidance - Newborn Tran
• • •
|
Development - Physical
• • •
|
|
Anticip. Guidance - Nutrition
• • •
|
Development - Cognitive
• • •
|
|
Anticip. Guidance - Parental Wel
• • •
|
Anticip. Guidance - Newborn Care
• • •
|
|
Additional Information
|
|
|
Referrals
• • •
|
Maternal influence on feeding issues
• • •
|
|
goals for next visit
|
Evaluate at next visit
|
|
follow-up Visit
|
|
|
Time spent in consult
|
|
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Feeding Hx
|
|
|
|
|
|
New Field
|
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|
New Field
|
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New Field
|
|
