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NEONATAL CLINICAL ENCOUNTER FORM

GENERAL INFORMATION

NAME: STUDENT -IN-CHARGE:

DATE OF BIRTH ( MM/DD/YYYY) DATE OF ADMISSION:

AGE: SEX : CIVIL STATUS : DATE OF INTERVIEW :

RELIGION : PLACE OF INTERVIEW:

ADDRESS: INFORMANT:

RELATION:

ATTENDING PHYSICIAN: RELIABILITY: Excellent Very Good Good Fair Poor

CLINICAL HISTORY

CHIEF COMPLAINT :

HISTORY OF PRESENT ILLNESS

TEMPORAL PROFILE LEGEND

REVIEW OF SYSTEM

General

Musculoskeletal/
Integumentary

HEENT:

Respiratory:

Cardiovascular:

Gastrointestinal

Endocrine

Genitourinary

Neurological
FAMILY HISTORY

GENOGRAM: LEGEND:

IMMUNIZATION HISTORY

BCG

Hepatitis B

DPT/ Polio/ HIB

Rotavirus

Others

NUTRITIONAL HISTORY

Infant Feeding Complementary Feeding Food preferences/ Feeding Problems/ Food


Allergies
Breastfeeding Period
_____________________
Formula _________________________

DIET OTHERS

PERSONAL – SOCIAL AND ENVIRONMENTAL HISTORY

NUMBER OF HOUSEHOLD
TYPE OF DWELLING
MEMBERS

ELECTRICITY DRINKING WATER SOURCE

EXPOSURE TO TOBACCO/
WASTE/ GARBAGE DISPOSAL
TOXINS/ BIOHAZARDS, ETC.

OTHERS PERTINENT HISTORY OF TRAVEL

STAKEHOLDER ANALYSIS

Name/ Role Stake / WIIFM Stand on the Issue Intensity of Stand Degree of Insight/ Action
Influence
Patient Name: Age: Sex: Birthdate:

BIRTH HISTORY

Date of Birth: ____________ Time of Birth: __________


Birth Weight _______kg Gestational age _________ wks [ ] AGA [ ] SGA [ ] LGA
Type of delivery: [ ] NSD [ ] CS [ ] Foreceps [ ] Other
Apgar 1 min _______ 5 min _________

Rupture of Membranes: __________________________ Transition Period


Fetal Distress : _________________________________
Sedation / Anesthesia: ___________________________ Initial VS: HR _____ RR_____ T _____ BP _____
Resuscitation: __________________________________ Glucose ________ CBC _________ Blood Type ________
Complications: _________________________________

MATERNAL HISTORY

Maternal Illness / Complications this pregnancy:


PRENATAL CARE AND TESTING
[ ] Diabetes ______________________________________
Age _________
[ ] Hypertension__________________________________
[ ] Pre-eclampsia _________________________________
Gravida ________ Para_______
[ ] Infection ______________________________________
Term ______Preterm _______Abotion _____ Living _____
[ ] Spotting ______________________________________
EDC ___________
[ ] Others: ______________________________________

Prenatal Care at ____________________


MEDICATIONS: ___________________________________
No. Of visits ________________
___________________________________________________

Blood Type ______________ Pregnancies and Complicatons


HepBsAg__________
HepBsAb ____________ G1 ________________________________________________
VDRL /RPR ____________________ G2 ________________________________________________
GC / Chlam _________________ G3 _______________________________________________
HIV _______________________ G4 ________________________________________________
Ultrasound screening ___________________________
Other tests / issues _________________________________
Patient Name: Age: Sex: Birthdate:

PHYSICAL EXAMINATION
ANTHROPOMETRICS NECK
Weight: ________kg Length: ________ cm Clavicle: ____________________________________
HC: _________ cm AC: _________ cm CC: _________ [ ] Masses: _________________________________
VS: HR: _________ RR: _________ T: __________
BP: all extremities: _________________
GENERAL APPEARANCE CHEST
[ ] Alert [ ] irritable but consolable [ ] Retractions
[ ] irritable but inconsolable [ ] lethargic [ ] Deformities
[ ] unresponsive Symmetry : _______________________
Breath Sounds: ____________________
COLOR HEART
[ ] Pink [ ] cyanotic [ ] acrocyanosis Apex beat: _________________________
[ ] jaundiced [ ] pale [ ] plethoric Hearth Sounds: S1: _____________________
S2: _____________________
Murmur:
SKIN ABDOMEN
Texture: ______________________ Umb art: ________________ Umb vein: _______________
[ ] Bruising __________________________ [ ] Masses: ____________________
[ ] Birthmarks _______________________ Bowel Sounds ___________________
[ ] Rushes ___________________________ [ ] Others ___________________
[ ] Other Findings (e.g. nevi)________________________
HEAD GENITALIA
Ant fontanel: _________________ [ ] discharge [ ] mucosal tag
Post fonanel: _________________ [ ] hydrocoele [ ] hernia [ ] urethral defect
Sutures _________________ [ ] Others: ___________________
[ ] caput [ ] cephalhematoma [ ] fracture
EYES BACK
Shape / Symmetry :_________________ Spine: _______________________________
Sclerae: _________________________ Hips: _______________________________
Conjunctivae: _____________________ Anus: ______________________________
Pupils: __________________________ [ ] Others: ______________________________
Red Reflex: ________________________
[ ] discharge [ ]tearing [ ] swelling
[ ] corneal light reflex
EARS EXTREMITIES
Pinnae: _________________________________ Pulses: ________________
Canal: ___________________________________ [ ] Others ________________________
[ ] sinus [ ] skin tag
NOSE NEUROLOGIC EXAM
Septum: ________________________ Tone: ____________________________
Nares: _________________________ Movement: _______________________
ORAL CAVITY Reflexes: ________________________
Tangue: _______________________ [ ] Sucking
Palate: __________________________ [ ] Rooting
Lesions: _____________________________ [ ] Moro
[ ] Grasp