ASSESSMENT TOOL ON CHILD HEALTH NURSING

1) BASE LINE DATA:

NAME : ____________________
AGE : ____________________
SEX : ____________________
RELIGION : _________________
NATIONALITY : _____________
EDUCATION : _______________
ADDRESS :
I.P. No: _____________
WARD: _____________
BED No: _____________
UNIT : _______________
DOCTOR : _____________________
D.O.A : __________________
No. of times Admitted : ___________

___________________________ a) Frequency of Hospitalization _______

___________________________ b) Duration of Hospitalization ________
___________________________
___________________________
___________________________
___________________________

PHONE No. : __________________ Diagnosis: _____________________

HOSPITAL : __________________

II) CHIEF COMPLAINTS:

1)
2)
3)
4)
5)
 III) HISTORY OF PRESENT ILLNESS:
a) Onset: ___________ Sudden ____________ Graduate __________
b) Duration: __________ Days ______ Weeks ______ Months ________
Year ____________ Frequency _______________

IV) CARDINAL SYMPTOMS:

a) Onset : ____________ Sudden_____________ Gradual __________
b) Onset : __________ Duration __________ Characteristics __________
c) Onset : __________ Duration __________ Characteristics __________
d) Onset : __________ Duration __________ Characteristics __________
e) Onset : __________ Duration __________ Characteristics __________

IMMUNIZATION RECORD FOR CHILD:

AGE DPT POLIO HEP-B DT TT BCG MEASELS VIT-A DOSE REMARKS

ASSESSMENT OF CHILDHOOD ILLNESS:
Medical Problems associated with : Infancy or Toddler:
Disease Condition: Diarrhoea _______ Mumps _______ Measles ________
Poliomyelitis _______ Whooping Cough ______ Febrile Convulsions _______
Skin infections ______ Nutritional diseases ____ Period of suffering
_________
Few days _______ 15 days ______ 3-4 Weeks ______ Months ___________

TREATMENT:
Homeopathy____ Allopathy ____ Unani ______ Any other ______ Home
remedies if yes, specify __________

V) PAST HEALTH HISTORY:

a) Previous Health Status: Healthy ____________
Frequency suffered with Health problems _______________
b) Previous Hospitalization if any: Yes __________ No _________
If yes, specify cause: _________________
Treatment taken : Regular _______ Irregular ________ Outcome _________
Follow up care ___________
c) History of surgery: Yes ___________ No_____________
If yes, specify type of surgery ____________ cause _______________
Post operative period ______________ Out come o surgery ____________
d) History of Tracumatic Injuries: Yes ____________ No_________
If yes, specify ________________ Treatment taken _________________
e) Delayed mile stones:
Growth retardation ______________
History of any congenital malformations
I)
A) HEAD FOR HYDROCEPHALUS:
Head circumference ____________
Bulging fontanels: Yes _____ No _____ Open __________ Closed ________
Anterior Fontanels: Open ________ Closed________ If closed when _______
Posterior Fontanels: Open ________ Closed________ If closed when _______
Basing Fore head: Yes __________________ No _______________
Scalp Shiny: Yes ___________ NO _____________
Eyes: Symmetric _________ Asymmetric __________ Sunset eyes ________
Strabiamus _________________ Nystagmus _______________
Vomiting: Yes ______________ No ______________

B) MICROCEPHALY: Yes _______ No ________

Head Circumference: Yes___________ No__________

II) G.I. MALFORMATION:

a) Cleft Lip: Yes ___________ No ___________
If yes, specify: Unilateral __________ Bilateral ____________

b) Cleft Palate: Yes ____________ No ___________

If yes; Cleft of Uvula ___________ Cleft of soft palate __________
Cleft of hard palate ____________ Cleft of soft and hard palate __________
Poor Sucking: Yes _____________ No _______________
Eating Difficulty : Yes ___________ No __________
Nasal Speech : Yes ___________ No _____________

c) Trachea Esophageal Fistula:

Yes _________ No ___________
 Birth Weight ____________
Excessive Secretions: Yes ________ No __________
Constant Drooling: Yes __________ No _________
Intermittent Cyanosis: yes ________ No ________
Abdomen Distention: Yes ___________ No _______
Coughs/Chokes after food: Yes__________ No __________
Poor feeding: Yes _________ No ___________

d) Gastro Esophageal Reflex disorder:

Weight ______ Height _________
Poor weight gain: Yes ________ No ________
Dysphasia: Yes ___________ No ___________
Vomiting: Yes ________ No ___________
Abdomen pain: Yes __________ No ________
If yes duration _________ Type _____________ Characteristics ___________

e) Hirsch prang’s disease: Yes __________ No ________

Meconium passed in the first 48 hours of life(delivery) _________________
Vomiting: Yes ________ No ________
Abdominal distention: ___________ No ____________
Constipation: Yes __________ No _________

f) Pyloric stenosis: Yes ______ No ________

Vomiting ________________
Loss of weight _____________
Constipation ______________
Visible Gastric Peristaltic waves _____________
g) Anorectal Malformation:
Yes _________ No ____________ If yes specify ____________
Imperforate anus _________ Rectoperineal fistula ___________
Anal Atresia ____________
Persistent Diarrhoea ______________

III) CONGENITAL CARDIAC DEFECTS

A cyanotic heart disease ____________
Chest pain : Onset : Sudden ___________ Gradual __________
Duration ____________ Characteristics _____________
Radiation ______________
Aggravating factors ___________________________________________
Relieving factors ______________________________________________
Dyspnea : Onset : Sudden ____________ Gradual ______________
Duration : Hours ____ Days ____ Weeks ____ Months ____ Years _____
Dyspnea at rest ______________ Activity ____________
Aggravating factors ___________________________________________
Relieving factors _____________________________________________
Wheezing : Present __________ Absent _______________
Audible _________________ Heard only by stethoscope _______________
Wheezing present at whether change __________________

Cyanotic heart disease:

Dyspnea : Onset : Sudden _____________ Gradual ____________
Duration : Hours____ Days____ Weeks____ Months____ Years____
Dyspnea on rest________ Activity________
Aggravating factor ______________________________________________
Relieving factor _________________________________________________
Cyanosis : Present __________ Assertive__________
Present : During Act ____________ Present at rest _____________
Area of Cyanosis : Nail Beds ______ Oral cavity ______ Tip of the nose _____
Earlobes __________
Hyper Cyanotic Spells: Present _________ Absent _________
If present : Moning _____ Crying _____ During feed _____ After feed _____
Painful Procedure : ___________________________
Aggravating factor : _________________________________________
Fatigue : Present __________Absent __________
Population : Present __________ Absent ____________
Weight gain according to age: Appropriate ________ Inappropriate _________

NEUROLOGICAL DEFECTS:
a) Spinabifida : Yes _______ No ________
If yes specify type __________________________
Spina occutta __________
Spina cystica __________________ Encephalocele _________________

Genito Urinary Malformation : Yes ______ No ______

If yes, urethral meatus ________ Dorsal ________ Ventral ________
a) Cryptochidism : Yes ______ No ______
If yes, unilateral _____________ Bilateral _____________
Ambiguous Genitalia : Yes ______ No ______

a) Skeletal Muscle Deformities :

Polydactly ______________
Syndactly _______________
Congenital hip, dysplasia : Yes ______ No ______
If yes, left hip _________ right hip _________
 Achondroplasia : Yes ______ No ______
GENETIC DISORDERS:
a) Down Syndrome ____________
b) Edward Syndrome ___________
c) Patons Syndrome : Yes ______ No ______
d) Turners Syndrome : Yes ______ No ______
e) Kline filter Syndrome : Yes ________ No _______

V) PERINATAL HSTORY OF MOTHER:

General Health of Mother during Pregnancy
Good Average __________ Poor __________
Complication of pregnancy : Yes ______ No ______
If yes specify
1. _______________________
2. _______________________
3. _______________________

Antenatal Check ups : Regular ________ Irregular _____________

Nature of the delivery : Term ______ Preterm ______ Post dated ______
Normal ___________ Forceps _____________ Caesarian __________
Birth weight of the baby : __________________
Whether baby cried immediately : Yes ______ No ______
Cyanosis at Birth : Yes ______ No ______
Jaundice : Yes ______ No ______

RESPIRATORY PROBLEMS:
Baby kept in NICU after birth : Yes ______ No ______
If yes, specify _____________________
VI) Developmental History
NEONATE : a) Weight __________ Height ___________
Head circumference _____________ Chest Circumference ________________
Reflexes :
1) Sucking ___________
2) Routing ___________
3) More Reflex _____________ Yes ______ No ______
4) Tonic neck ____________ Present __________ Absent __________
5) Dancing Reflex : Present __________ Absent __________
6) Gag Reflex : Present __________ Absent __________
7) Plantar Reflex : Yes ______ No ______
8) Babinski Reflex : Present __________ Absent __________

FINE MOTOR:
Hold hands in tight position : Yes ________ No _________
Plamer Grasp : Reflex : Present __________ Absent __________

GROSS MOTOR:
Lies in flexed position __________ Yes _____ No _____ Age _____
Head sags when baby pulled from supine to sitting position:
Yes _____ No _____ Age _____
Turns head to the side when prone : Yes _____ No _____ Age _____
Makes crawling movements, when prone on flat surface :
Yes _____ No _____ Age _____
Pushes with feet against a hard surface at more forward :
Yes _____ No _____ Age _____
SENSORY:
Startled by sounds : Yes _____ No _____ Age _____
Fines on objects brought in front of eyes : Yes _____ No _____ Age _____

COGNITIVE DEVELOPMENT :
Perceives self and parents as one : Yes _____ No _____ Age _____
Responses are generally limited to discomfort : Yes _____ No _____ Age
_____
Gaining satisfaction from feeding and being held, rocked cuddled : Yes _____
No _____ Age _____
In need for sucking pleasure : Yes _____ No _____ Age _____
Quiets when picked up : Yes _____ No _____ Age _____
Develops bonding with parents : Yes _____ No _____ Age _____

VOCALIZATION: Yes _____ No _____ Age _____

Responds to human voices : Yes _____ No _____ Age _____
Open and closes mouth as adult speaks : Yes _____ No _____ Age _____
Cries when hungry/uncomfortable : _________________
Begins to coo : Yes _____ No _____ Age _____
Play : Soft cuddy toys : Yes _____ No _____ Age _____

INFANCY:
A) Weight ____________ Height ______________
Head circumference ____________ Chest circumference ______________
Reflexes: 1)
2)
3)
Teething : Age of Eruptions : _________________

B) Fine Motor:
Group Reflex : Present _____________ Absent ____________
Pineer Grasp : Present _____________ Absent ____________
Preference of using dominant hand ________________

C) Gross Motor:
Rolling over : Yes _____ No _____ Age _____
Sitting : Yes _____ No _____ Age _____
Crawling : Yes _____ No _____ Age _____
Cripping : Yes _____ No _____ Age _____
Standing : Yes _____ No _____ Age _____
Walking : Yes _____ No _____ Age _____

Any other history of delayed

Mile stone : Yes _____ No _____
If Yes, Specify _________________________

d) Sensory:
Binocular Vision : Yes __________ No _____________
Turns head directly to source of sound : Yes _____ No _____ Age _____
Increased Perception : Yes _____ No _____ Age _____
Turns head to follow sound : Yes _____ No _____ Age _____
Responds when called by name : Yes _____ No _____ Age _____

e) Cognitive Development:
Ability to bring hands to mouth : Yes _____ No _____ Age _____
Thumb sucking : Yes _____ No _____ Age _____
Separation Anxiety : Yes _____ No _____ Age _____
Expression of emotions : Yes _____ No _____ Age _____

f) Vocalization :
Smile : Yes _____ No _____ Age _____
Ability to coo : Yes _____ No _____ Age _____

TODDLER:
a) Weight ___________ Height _____________
Head circumference : _________ Chest Circumference __________
Reflexes __________ Present __________ Absent __________
Teething __________ Present __________ Absent __________
b) The Fine Motor:
Grasp Reflex : Present _____________ Absent ______________
Frequency of using document hand __________________
c) Gross Motor
walking with support : Yes _____ No _____ Age _____
Running : Yes _____ No _____ Age _____
Walking upstairs : Yes _____ No _____ Age _____
Riding Tricycle : Yes _____ No _____ Age _____\
d) Language:
Two words with meaning : Yes _____ No _____ Age _____
Ten words with meaning : Yes _____ No _____ Age _____
Simple sentences : Yes _____ No _____ Age _____
Telling a story : Yes _____ No _____ Age _____
e) Personal and special:
Plays a small ball game : Yes _____ No _____ Age _____
Knows Gender : Yes _____ No _____ Age _____
PRE SCHOOL CHILDREN

a) Physical Development : Weight ____________ Height __________

Eruption of permanent teeth : Yes _____ No _____ Age _____

b) Gross Motor:
Rides tricycle : Yes _____ No _____ Age _____
Climbs Stairs : Yes _____ No _____ Age _____
Jumps with both feed : Yes _____ No _____ Age _____

c) Fine Motor:
Coordinated finger movements : Present ___________ Absent ___________

d) Sensory :
Reading comprehension : Yes _____ No _____ Age _____
Visual Acuity : Complete _________ Partial _______ Absent ________

e) Language :
Vocabulary : Good __________ Average __________ Poor __________
Names primary colors ___________ ask meaning of words _____________
Repeat sentences of 12 syllables _________________________________
Counts 1 to 10 _______________ Vocabulary of 21000 words ___________

f) Socialization :
Activities of daily living : Good ________ Average ________ Poor _______
Identifying Sex : Yes _____________ No _______________

g) Cognitive :
 Perception : Good __________ Average _________ Poor ____________
Judgment : Good __________ Average _________ Poor ____________
Family Relationship : Good ________ Average _______ Poor _________
Development delays : Speech : Normal ______ Shuttering ______ Language

delay _____ Starting spells _______

h) Play :
Tricycle : _______ Crayons paints _______ Hand Puppets _______ Bocks
Puzzles __________ Team Play __________ Trucks, Cars play ______

i) Shows differences in gender through play _____________

SCHOOL AGE CHILDREN : (6-9 years)

a) Physical development : Weight ____________ Height ____________
Dentition : Starts to lose temporary teeth : Yes _____ No _____ Age _____
Acquires first permanent molars, medical incisors, lateral incisors :
Yes _____ No _____ Age _____
b) Fine Motor :
Knows right from left hand : Yes _____ No _____ Age _____
Draws a person with 21-1 parts : Yes _____ No _____ Age _____
Print words and learning cursive writing : Yes _____ No _____ Age _____
Improved eye hand coordination : Yes _____ No _____ Age _____
Psycho Sexual : Curiosity of sexual exploration continues _____________

c) Gross Motor :
Rides Bicycle : Yes _____ No _____ Age _____
Runs, Jumps, climbs, Hops : Yes _____ No _____ Age _____
Constantly in motion : Yes _____ No _____ Age _____
Improved coordination : Yes _____ No _____ Age _____
d) Self Care :
Feeding skills : Like to eat with fingers : Yes _____ No _____ Age _____
Stuffs food into Mouth : Yes _____ No _____ Age _____
Talkative while eating : Yes _____ No _____ Age _____

Combing and Dressing Skills:

Needs to be reminded to wash hands : Yes _____ No _____ Age _____
Wears what ever selected by parents : Yes _____ No _____ Age _____
Can brush and comb hair : Yes _____ No _____ Age _____

e) Cognitive Development :
Increased attention span : Yes _____ No _____ Age _____
Described objects : Yes _____ No _____ Age _____
Can tell time : Yes _____ No _____ Age _____
Knows date, Month and Season : Yes _____ No _____ Age _____
Jealous of siblings : Yes _____ No _____ Age _____
Fears injury to body : Yes _____ No _____ Age _____
Takes small objects from others : Yes _____ No _____ Age _____

f) Vocalization :
Follow series of 3 commands : Yes _____ No _____ Age _____
Responses to praises and recognition : Yes _____ No _____ Age _____
Repeat sentences of 10 – 12 words : Yes _____ No _____ Age _____
Has a vocabulary of 2500 words : Yes _____ No _____ Age _____
Develops telling jokes : Yes _____ No _____ Age _____

SCHOOL AGE CHILDREN : (9-12 YEARS)

a) Height _______________ Weight __________________
Dentition : Acquires medical and lateral incisions : Yes____ No____ Age ____
b) Fine Motors :
Use both hands independently : Yes _____ No _____ Age _____
Draws person with 18-20 parts : Yes _____ No _____ Age _____
Prints fluently cursive writing improved : Yes _____ No _____ Age _____

c) Gross Motor :
Performs tricks on bicycles : Yes _____ No _____ Age _____
Races : Yes _____ No _____ Age _____
Participates in organized sports : Yes _____ No _____ Age _____
Throws ball skillfully, overhand and understand :Yes____ No____ Age____

d) Self Care:
Feeding skills
Handles eating utensils skillfully : Yes _____ No _____ Age _____
Improved table manners : Yes _____ No _____ Age _____
Less talking when eating : Yes _____ No _____ Age _____
Critters table manners of parents : Yes _____ No _____ Age _____
Dressing and grooming skills : Yes _____ No _____ Age _____
Likes to some cloths continually : Yes _____ No _____ Age _____
Enjoys selecting own cloths : Yes _____ No _____ Age _____
Leaves cloths, when they are removed : Yes _____ No _____ Age _____
Enjoys wearing current style of cloths : Yes _____ No _____ Age _____
Needs constant remanding of personal hygienic :Yes____ No____ Age____

e) Cognitive Development:-
Develops abstract and seductive reasoning : Yes _____ No _____ Age _____
Interested in “why” and “Now” : Yes _____ No _____ Age _____
 Short interest span : Yes _____ No _____ Age _____
Ethical sense and realistic : Yes _____ No _____ Age _____
Begins to tahink about vocation : Yes _____ No _____ Age _____

f) Vocalization:
Follows suggestions better than requests : Yes _____ No _____ Age _____
Is obedient : Yes _____ No _____ Age _____
Oral vocabulary of 7200 words : Yes _____ No _____ Age _____
Reading vocabulary of 50000 words : Yes _____ No _____ Age _____
Gives precise, dictionary definition of words : Yes_____ No_____ Age_____
Enjoys riddles : Yes _____ No _____ Age _____

g) Play:
Active play _________ Group play _________ Dramatic Play _________
Table games __________ Bicycle __________ Jump ropes __________
Ball/bats ____________ Dance:____________ Puzzles _____________

ADOLESENCE:

Physical Development : Weight ___________ Height _____________

Moral Development : Thinking : Abstract ________ Yes ______ No ________
Cooperative: yes __________ No ___________
Emotional Development :
Secondary Sexual Characteristics present _________ Delayed __________
Others if any _________________________________________
Social Development:
Relation with Friends : Good _____________ Poor_____________
Attitude towards parents : Good _____________ Bad_____________
Social isolation : Yes ______________ No _____________
Others if any _________________________________
Language Development:
Oral Speech Ability : Yes ________ No ___________

Abstract Reasoning : Yes _________ No ___________

Articulation : ______________________________

Spiritual Development :
Belief of God : Yes _________ No _____________

Family History :
1) Parents consanguineous marriage : Yes __________ No __________
2) Type of family : Nuclear ____________ Joint ____________
3) Position in the family : Son ________ Daughter _____ Relatives ______
4) No. of adults ________ No. of children ___________
5) Any known illness in the family _______________
a) ______________
b) ______________

ANY FAMILY HISTORY OF:

Births defects : Yes ___________ No __________
If yes, state the relationship __________
Infants deaths : Yes ____________ No ___________
If Yes ___________ state the relationship ____________
Seizures disorders : Yes ___________ No ___________
If yes, state the relationship _______________
Cardiac Problems : Yes _____________ No ____________
If yes, state the relationship _______________
If any other specify ________________

FAMILY TREE:
Key :
Male :
Female :
Disease :
Death :
Client :

SOCIO ECONOMIC STATUS HISTORY :

A) Education: Mother ______________ Father _____________
B) Occupation : Mother ____________ Father ______________
C) Income : Per Month ____________ Per anum ____________
D) Housing : Kutcha _________ Pucca ________ No. of rooms
________
E) Lighting : Ventilation poor _________ Good _____________
F) Water supply : Well ________ Bore Well ________ Public tap
__________
G) Individual tap supply _______________
H) Drainage : Closed _____________ Open _______________

DAILY LIVING ACTIVITIES:

1) Bath : Daily ___________ No. of times ____________
2) Brushing : No of times ________ Types of Brush ____________
3) Voiding : Frequency ____________ Time ________: AM ____ PM ____
4) Constipation : _____________ Diarrhoea _________
5) Sleep : Usual bed time ________Time of awakening ________ House of
sleep ___________ midday rest __________ Nature of sleep __________
 Sound ___________ Disturbed ______________ Insomnia
________________
6) Bed time virtuals : Yes ________ No______ if yes, specify ________

DIETARY HISTORY:

A) Breast feeding _______ stating time _______ Duration of feeding ______

B) Bottle feeding : Yes _____ No _____ If yes duration of feeding
_________
C) Weaning : Type of foods ___________
Starting time ______________ No. of times food intake _____________
D) Vegetarian _____________ Non-vegetarian ___________________
If Non-vegetarian type _____________ Frequency ________________
E) Staple food : Rice ______ Wheat ______ Jowar ______ Others ______
F) Food preferences fruits : Yes ______ No ______ If yes specify
_________
Chocolates _______ Ice Creams ______ Sweets _______ Cakes _______
If any other specify ___________
Name of the food : Mostly _______ Sometimes _______ Consumed ________
Occasional __________ Never __________

Name of the food Mostly Sometimes Occasionally Never

PHYSICAL EXAMINATION :

General Appearance: Healthy_____ Acutely ill_____ Chronically ill_____

Stages of Comfort: Comfortable _______ Distressed ______ Apathy________
Lethargy ________ Restless ________ Pleasant : Mood Pleasant ________
Depressed _________ Cooperative _________ Non-Cooperative__________
Level of consciousness : Conscious _______ Drowsy ______ Semi conscious
________ Unconscious _________ Stupor __________
Mental Status: Fearful______ Anxious______ Irritation______ Angry______
Withdrawal ________ Agitation ________ Facial Expressions __________
Appropriate eye contact ________
Speech : Clear ___________ Blurred _____________ Fluent _____________
Measuring ______________ Aphasia ________________
Orientation: Place ___________ Time ____________ Person _____________
Personal Hygienic: Good _________ Clumsy ________ Appropriate ________
Inappropriate _______________ Body Odor _______________
Perspiration: Profuse __________ Moderate __________ Absent __________
Position of Body: Symmetric _________ Asymmetric _________ Kyphosis
________ Lordosis ___________ Scoliosis __________
Body Built: Obese _________ Moderate _________ Thin _________ Height
___________ Weight __________
Recent Weight gain: Yes ________No ________ If yes, specify __________
Recent Weight loss: Yes ________No ________ If yes, specify __________
Vital signs: _________ Temperature _________ pulse ________ Respiration
__________ B.P.__________
Inspection : Head for Hydrocephalus ________________
Head circumferences __________________
Bulging of fontanel : Yes ________No ________
Anterior fontanel : ____________ If closed _____________ Open
If closed when ______________
Posterior Fontanel: Open_________ Closed________ if closed when_________
Scalp: Hair distribution thick ___________ Scanty ____________
Texture: Soft __________ Silky ___________ Shine ness of scalp __________
Crushing ______________
Face: Normal __________ Pallone _________ Cyanosed _________ Flushed
________ Putty ________ Periorbital swelling ______ Moon face __________
Skin Colour: ____________ Normal Cyanotic: Yes ________ No ________
If yes central ____________ Peripheral __________
Nails: Normal ___________ Cyanosis ___________ Clubbing ___________
Vertical folds ___________
Eyes: Symmetric_________ Asymmetric__________ Dry_________ Moist
_________ Red________ Yellow________ Pale________ Discharge________
Exopthlmas ___________ Blurring _____________ Sunset eyes __________
Eye Lids:_________ Normal_________ Swelling__________ Style_________
Pupil : Reaching to light, constriction____________

Dilatation:
Lens: ___________ Transparent _____________ Opeque ____________
Ears: _________ Symmetric_________ Asymmetric________ Pain ________
Discharge _____________ Duration _____________
Low set: _______________ Unequal positioning_____________ foreign bodies
____________ Tenderness____________ Impaction ______________
Hearing : Normal ________ partial deafness ____________ deafness, non neck,
septal deviation
Nose: Normal_________ Septal deviation___________ Rhinorehoea ________
Epistaxis _____________ Polyps ___________ Injuries ____________
Mouth: Old mucose : Normal _____________ Pallor Redness _____________
leukoplaquia ___________
Lips: Pink ________ Pale ________ Dry ________ Cyanosed __________
Crackles________ Cleft lip__________ Unilateral________ Bilateral________
Gums: Pink ________ Red ________ Swollen ________ Bleeding ________
Pus ____________
Teeth: Occlusion ________ Malocclusion ________ Permanent ________
Temporary ________ Pyorrhea ________
No. of teeth, upper and lower jaws __________, cavities __________
Tongue: Pink ________ Pale ________ Red ________ Cyanosis ________
Coated ________ Dry ________ Moist ________ Tongue tic ________
Palate: Normal ___________ Clieff palate ________ Hard Palate __________
Soft Palate __________
Neck: Normal __________ short, stiffness___________ Webbed___________
Tonsils : Palpable_________ Non Palpable______ Lymphedinopathy________
Thyroid: Normal __________ Enlarged _________ Nodular __________
Trachea: Middle ___________ Mobile ____________ Shifted __________
Tracheoesophageal fistula _______________
Chest: Symmetric___________ Asymmetric___________ Shape___________
Normal _____________ Pigeon ____________ barred chest __________
Funned __________
Breast: Symmetric____________, Asymmetric___________ Tender________
Non tender___________ Masses____________ Discharge________
Gynaecomastic_________
Abdomen: Shape_________ Flat________ Concave________ Round_______
Distended____________ Ascitis__________ Upshunt__________
Umbilical: Position color__________ Hernia__________ Discharge_________
Moist____________ Dry_____________
G.I. Tract: Appetite___________ Vomiting__________ Diarrhoea__________
Oesophagel atresia_________ anorexia__________ Abdominal pain_________
Constipation____________ Malena___________ Imperforate anus__________
Stool: Normal___________ Abnormal Characteristics_______________
Pin worms in stool______________ Perennial pruritis____________
Supra public pain_________ Yes______ No______ If yes, duration__________
Dysuria__________ Haematuria________ Anuria________ dribbling (or)
Incontinence ______________ Yes________ No________ Polyuria_________
Oliguria__________
Male genital birth defects ___________ If any _____________
Urethral meatus : Central________ Dorsal ________ Ventral ________
Scrotum tender : Non tender_________ swelling________ redness________
Illumination(or)Undascanded testis__________ Any congenital abnormalities/
defects ____________
Extremities: Symmetric________ Asymmetric________ Deforming________
Oedema: Pitting or non pitting.

Palpation:
Abdomen: Soft mass palpate _________ Non palate ___________ Tenderness
_____________ Ascitis ________
Liver: Non palpable__________ Palpable________ Tender ________
Spleen: Non palpable__________ Palpable________ Tender ________
Urinary Bladder: Distended _____________ Non distended _____________

Percussion:
Skull ________________ Malewen’s sign
Lungs _______________ Resonance, Dullness
Hyper _______________ Resonance flatness
Clear ________________ Tympanic
Abdomen_________ Dullness__________ Shifting dullness thrill__________
Bladder__________ Dullness____________ Tympanic____________

Ascultation:
Heart: S1___________ S2___________ S3_____________ S4____________
Murmurs: Present _________________ Absent ______________
Lungs: Normal breath sounds _____________ Crepitus_________
Ronchi________ Wheeze__________
Bowel sounds _______________ Present____________ Absent____________
Regular______________ Irregular_________________

Lab Investigation