SURNAME: _________________________________

( ) Manilan
( ) NonManilan

Skin: ________ color, _________ skin turgor

( ) rashes, ( ) hematoma, ( ) desquamation

GENERAL DATA
Live baby _______ born ______ term to a _____ y/o mother
G_P_ via _____________ on _____________________.
Prenatal history:
LMP
:____________________
AOG
:____________________
EDC
:____________________
Patients mother had a total of ____ prenatal check-ups
done at _______________________ , first prenatal check-up
was done at _____ AOG. Last check-up was ______.
Laboratory examinations done:
( ) CBC
( ) Blood typing
( ) Urinalysis
( ) Ultrasound
( ) OCCP
( ) HbsAg
( ) Others: _______________________________
Maternal
(
(
(
(
(

Vital signs:
HR=
RR=
Temperature=
Head: ( )caput, ( )molding, ( )craniotabes, ( )
cephalhematoma
Face: ( )asymmetry
Eyes: ( )conjunctivitis, ( )discharge
ENT: ( )patent nose, ( )cleft lip, ( )cleft palate
Chest: ( )breast bud, ( )clavicular fracture, ( )NRRR, (
)clear breath sounds
Abdomen: ( )flat/globular, ( )masses, ( )2A:1V
Genitals: ( )Normal, ( )Abnormal
Trunk and Spine: ( )Spina bifida, ( )deformity
Extremity: ( )cyanosis, ( )edema, ( )polydactylism, ( )
syndactylism,
( ) club foot, ( ) full and equal pulses
Reflexes: ( )Moro, ( )Sucking, ( )Grasping

Illness:
) Intake of multivitamins
) Intake of ferrous sulfate
) Intake of illicit drugs
) Use of teratogenic substances
) Exposure to radiation

ANTHROPOMETRICS

BL
BW
HC
CC
AC

Comorbid Factors:
( ) Hypertension
( ) Diabetes
( ) UTI
( ) Thyroid problems
( ) Asthma
( ) History of twinning
OB History: G__P__ (___-___-___-___)
Year
Sex
Via
Term

=
=
=
=
=

APGAR SCORE
1 min
5 mins

Plac
e

FMC

G1
G2
G3
G4
G5
G6
G7
G8
G9
G10

BW

15
mins

Appeara
nce
Pulse
Grimanc
e
Activity
Respirat
ion
TOTAL
SCORE
ASSESSMENT

Live baby ____________ born __________ term to a _____ y/o

G_P_ (___-___-___-___) mother, __________ weeks AOG by
LMP, _______ weeks by Ballard, via _________.
Dr.
__________________
JI______________

General survey: ___________ activity, __________ cry,

____________ tone
( ) cardiorespiratory distress

10
mins

PGI__________________

NAM
NAME:

__________________________________________

Sex:

_____________________

Date

of

3
cracking,
pale
areas, rare
veins
Bald areas
creases
anterior
2/3

4
parchment
, deep
cracking,
no vessels
Mostly bald
creases over

5
leathery,
cracked,
wrinkled

raised
areola 3-4
mm bud
formed &
firm
instant
recoil

full areola 5-10 mm bud

testes
down,
good
rugae
majora
large,
minora
small

testes pendulous, deep

rugae

birth:

_____________________________

Neuromuscular Maturity

Physical Maturity
SIGN
-1
0
Sticky, friable, gelatinous,
red,
transparent
translucen
t
none
Sparse
heel-toe 40- >50 mm
50mm: -1
no crease
<40mm: -2

1
smooth
pink,
visible
veins
Abundant
faint red
marks

Breast

imperceptib
le

flat areola
no bud

Eye/Ear

lids fused
loosely: -1
tightly: -2

barely
perceptibl
e
lids open
pinna flat
stays
folded

Genitals
(Male)

scrotum
flat, smooth

scrotum
empty,
faint rugae

Genitals
(Female)

clitoris
prominent
& labia flat

prominent
clitoris &
small labia
minora

testes in
upper
canal, rare
rugae
prominent
clitoris &
enlarging
minora

Skin

Lanugo
Plantar
Surface

Score
Weeks

-10
20

-5
22

0
24

5
26

sl. curved
pinna;
soft; slow
recoil

10
28

Score
2
superficial
peeling
&/or rash,
few veins
Thinning
anterior
transverse
crease
only
stippled
areola 1-2
mm bud
wellcurved
pinna; soft
but ready
recoil
testes
descendin
g, few
rugae
majora &
minora
equally
prominent
15
30

20
32

25
34

entire sole

thick cartilage ear stiff

majora cover clitoris &

minora

30
36

35
38

40
40

45
42

50
44