Newborn Examination

Infant's Name:(First, Middle, Last)
Birthdate:
Parent's Names:
Exam Date:
EDB: (Estimated Date of Birth) or EDD: (Estimated Due Date)
EGA: (Estimated Gestational Age)
Sex:
Weight:
Length:
OFC:
Apgar Score:
Resusitation:

None:
Free Oxygen:
Stimulation:
Other:

Suction:

None:
Bulb:
DeLee:
Clear:
Meconium:

General Appearance:
Skin Tone & Color:
Head:

Fontanels, Sutures:
Caput:
Molding:
Symmetry:

Ears: (placement)
Eyes:
Nose:
Mouth, palate, lips:
Lungs:

Respiratory Rate:
Retractions:
Silverman/Anderson Score:

Heart:

Rate:
Femoral Pulses:

Chest Circumference:
Abdominal: (masses, etc.)
Cord:
Breasts:
Hips:
Genitalia:
Anus:
Spine:
Extremities:
Reflexes:

Moro:
Tonic Neck:
Palmar Grasp:
Walking:
Plantar:
Babinski:
Blink:
Rooting/Sucking:

First Feeding at: (minutes/age)

By Breast:
By Bottle:

Medications:

Eye Care:

Parents Decline:

Vitamin K:

IM:__________ PO:__________
Parents Decline:

Parental Signature if declining:_______________________________

Examined by:
Infant's Care Provider:

Comments:

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