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Mother's Name Father's Name RPR HbsAg Bstrep
          
Delivery Physician Attending Physician Birth Date Discharge Date Sex Race (Check)
W B O
Gest. Age by Asses. EDC Weight Length Head Circum. Chest Abd. Apgar 1 min./5
min.
Mother's Age Grav. Para. Preg. Problem Mother Blood Infant Blood Labor (Hrs.)
Type: Type:
Membr. Rupt. Presentation Anesthesia Type Delivery Resuscitation Breast/Formula

*Code Each Item as Follows:

Admission Examination Discharge Examination
O - No Abnormality
Description of Abnormal Findings X- Abnormality Description of Abnormal Findings
          
1. General Appearance
(Maturity, Activity, Tone, Cry,
Color, Nutrition, Edema)

2. Skin
(Rashes, Jaundice, Hematoma,
Cyanosis)

3. Head, Neck
(Molding, Caput, Craniotabes,
Cephalohematoma)

4. Eyes
(Abnormalities, Conjuctiva, Red
Flex)

5. Ears, Nose, and Throat

(Lips, Gums, Palate)

6. Thorax
(Including Breast Hypertrophy)

7. Lungs

8. Heart
(Including Femoral Pulse)

9. Abdomen
(Including Umbilicus)

10. Genitalia
(Testes, Circumcision, Meatus,
Discharge)

11. Anus

12. Trunk and Spine

13. Extremities
(Including clavicles and
abduction of hip joints)

14. Reflexes
(Moro, Grasp, Sucking,
Swallowing)

Impression at Admission Discharge Diagnosis

Term Birth Living Infant Term Birth Living Infant
Other Other

Date Time Physician Signature Date Time Physician Signature

PATIENT IDENTIFICATION
Circumcision (If done)
Uncomplicated
Device
Comments

Physician Record of Newborn Infant

N5816 Rev. (09/30/2003)