Please check () to indicate findings

General Measurements Weight ____ kg

Head Circumference ____cm
Chest Circumference ____cm
Abdominal Circumference ___cm
Length____ cm

Head Molding____
Caput succedaneum ____ Cephalohematoma ____
Craniotabes____
Eyes Size and Shape:
Symmetrical___
Asymmetrical____
Eyes issues:
Strabismus ____
Epicanthal folds___
Brushfield spots____
Cataracts___
Discharge ____
Ears Normal position and shape ____
Ear pits/tags ____
Nose Midline____
Symmetrical _____
Patent ____
Nasal discharges_____
Nasal flaring ____
Mouth Lip:
Symmetrical____
Asymmetrical____
Tongue:
Symmetrical____
Asymmetrical____
Protruding___
Non-protruding___
Palate:
Intact___
Non-intact___
Epsteins pearls ____
Uvula:
midline____
non-midline___
Epsteins pearls ____
Neck Clavicles:
intact ____
non-intact___
Masses in neck ____
Torticollis_____
Chest Normal shape and size ____
Accessory nipples ____
Clavicles:
intact ____
non-intact___
Lungs Rales____
Ronchi____
Tachypnea____
Abdomen Round___
dome-shaped_____
non-distended____
Masses ____
Umbilicus Three vessel cord ____
Odorless____
 Please check () to indicate findings
Genitalia Female:
Vaginal discharge ____
Normal clitoris ____
Male:
Testes descended ____
Foreskin normal ____
Hypospadias____
Epispadias_____
Hips Ortolani ____
Barlow ____
Upper Extremities All fingers present ____
Nails ____
Extra digit ____
Normal joints ____
Lower Extremities All toes present ____
Nails ____
Extra digit ____
Normal joints ____
Back Spine:
Straight spine ____
Flat___
Midline___
Sacral dimple ____

Skin Color:
Pink____
Acrocyanotic____
Jaundice____
Turgor:
Spring back immediately when pinched_____
Does not pring back immediately when pinched_____
Texture:
Dry____
Smooth____
Soft____
Skin issues:
Milia___
Lanugo___
Petechiae___
Vernix Caseosa ___
Erythema Toxicum ____
Mongolian Spots____
Storkbites____
Cavernous Hemangioma____
Nevus flammeus
Neuro Rooting reflex ____
Suckling reflex ____
Grasping reflex____
Tonic neck reflex___
Placing reflex ____
Moro reflex____
Babinski Reflex ____
Patellar reflex ____
Galamt Reflex____
Landau's Reflex_____
Gag Reflex____
APGAR SCORE

BALLARD SCORE
 TAGOLOAN COMMUNITY COLLEGE

COLLEGE OF MIDWIFERY

NEWBORN PHYSICAL ASSESSMENT

I. Mothers History

Name: _______________________________________ Age: ___________

Address: _________________________________________________________________

Date of Birth: ________________ Educational Attainment: ______________

Religion: _______________Occupation: __________________________

Blood type__________

Date of Last Menstruation Period: ___________ Date of delivery: __________

Gravida: ___ Term: ___ Preterm: ____ Abortion: ____ Livebirth: ____ Stillbirth: ______

Presence of Multiple Gestation: _____________

Birth interval of current to immediate past pregnancy: _____________

Health Problems encountered during recent pregnancy___________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

II. Newborn Physical Assessment

Babys Name: ________________________ Sex of baby ______________________

Mothers Name: ______________________ Date and Time of Birth: ______________________

Gestational Age: _______________________ Apgar Score______________

GIVEN: Vitamin K_______ Hepatitis B_______ BCG________

 POST PARTUM ASSESSMENT TOOL

Part 1: Demographic Data:

Name: _______________________________________ Age: ___________
Address: _________________________________________________________________
Date of Birth: ________________ Educational Attainment: ______________
Religion: _______________ Occupation: __________________________
Reason for Visiting the Healthcare facility: ___________________________________________
_____________________________________________________________________________________
Date of Interview: ___________________________________

Part 2: Vital Signs:

Temperature: ____________ Pulse Rate: _____________ Respiratory Rate: ____________
Blood Pressure: _________ Height: ______________ Weight: _____________

Part 3: Health History:

Health Problems Encountered during RECENT PREGNANCY

Past Health History: [Any previous illnesses other than those listed above/ hospitalizations/ allergies during the most recent
pregnancy and labor?]
______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Family History: [Health of parents, siblings, spouse. Include factors such as cancer, heart, or kidney diseases, diabetes mellitus,
asthma, hypertension and mental illness]
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

Part 4: Functional health History:

Physical: Description of patients general appearance, hygiene, grooming, signs of distress, physical capabilities.
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

Mental: check orientation to time, place, person; Description of patients functioning educational status; ability to answer
questions; level of understanding.
_________________________________________________________________________________________________
______________________________________________________________________________________________________
_____________________________________________________________________________________________
Emotional: description of clients emotional status. Attitude towards newborn and motherhood including concerns/ feelings
______________________________________________________________________________________________________
__________________________________________________________________________________________________

Spiritual: description of patient spiritual life, number of times she goes to church, religious organization affiliation. Religious
beliefs and practices regarding diet, birth and blood transfusions
______________________________________________________________________________________________________
_______________________________________________________________________________________________
Part 5: Obstetrical History
Date of Last Menstruation Period: ___________ Date of delivery: __________
Gravida: ___ Term: ___ Preterm: ____ Abortion: ____ Livebirth: ____ Stillbirth: ______
Presence of Multiple Gestation: _____________
Birth interval of current to immediate past pregnancy: _____________

Please check () to indicate findings Yes no

PREVIOUS CAESAREAN SECTION
3 CONSECUTIVE MISCARRIAGES
STILLBIRTH
POST PARTUM HEMORRHAGE

Part 6: Postpartum Findings

Code Guide for Maternal Discomforts responses

Code Interventions of patient
1 None
2 Self-medicated
3 Sought advice of family member/ relatives
4 Consulted traditional birth attendant/hilot/ mananabang
5 Consulted health center
6 Consulted practice
7 Others__________ [specify]

Part 7: Current Medications

Name of Medication Dosage & Frequency Route Classification

Part 8Sleep/Rest Pattern

Before Pregnancy During Pregnancy

Usual Sleep Pattern/ Bedtime

Factors affecting sleep

Part 9: Maternal Nutrition [indicate frequency of meals/food likes & dislikes/usual timing of meal]
Diet: _______________________
Pattern/Food/ Fluid Intake:
Breakfast: ___________________________________________________________________________

Lunch: ______________________________________________________________________________

Dinner: ______________________________________________________________________________

Appetite [describe]: __________________________________________________________________

Part 10: Elimination

Characteristic
Frequency
Usual Amount
Consistency
Usual Appearance

Is the patient taking diuretics? ____________ If Yes, state reasons: _____________________________

Is the patient taking laxatives? ____________ If yes, state reasons: _____________________________

Part 11: Coping/Stress

Any stressful situations ever experienced during the course of present pregnancy?
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
________

Stress Management used/ Relaxation techniques employed:

______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
________

Part 12: Laboratory Result

Laboratory Exam Results Normal Values Interpretation Midwifery

Considerations/
Interventions
I. Physical Assessment (System Review Chart) Date: ____________

Vital Signs:
Pulse: BP: Temp.: RR: Height:
Weight: Fundic height

EENT

( ) Impaired vision ( ) blind ( ) pain ( ) hard of hearing

( ) reddened ( ) drainage ( ) gums ( ) deaf
( ) burning ( ) edema ( ) lesion ( ) teeth
( ) no problem

RESPIRATORY:
( ) asymmetric ( ) tachypnea
( ) apnea ( ) rales ( ) cough
( ) barrel chest ( ) bradypnea
( ) shallow ( ) bronchi ( ) sputum
( ) diminished ( ) dyspnea
( ) wheezing ( ) chest pain ( ) cyanotic
( ) No problem

CARDIOVASCULAR
( ) arryhythmia ( ) tachycardia ( ) numbness
( ) diminished pulses ( ) edema ( ) fatigue
( ) irregular ( ) bradycardia ( ) murmur
( ) tingling ( ) absent pulses ( ) pain
( ) No problem

GASTRO INTESTINAL TRACT

( ) obese ( ) distention ( ) mass
( ) dysphasia ( ) regididty ( ) pain
( ) No problem

GENITO-URINARY and GYNE weak

( ) pain ( ) urine color ( ) vaginal bleeding
( ) hematuria ( ) discharge ( ) noctoria
( ) Lochiarubra( ) Lochia serosa ( ) Lochia alba
() problem -

NEURO
( ) takingin ( )takinghold( ) letting go
( ) paralysis ( ) stuporous ( ) unsteady ( ) seizures
( ) lethargic ( ) comatous ( ) vertigo ( ) tremors
( ) confused ( ) vision ( ) grip
() No problem

MUSCULOSKELETAL and SKIN

( ) appliance ( ) stiffness ( ) itching ( ) petechiae
( ) hot ( ) drainage ( ) prosthesis ( ) swelling
( ) lesion ( ) poor turgor ( ) cool ( ) deformity
( ) wound ( ) rash ( ) skin color ( ) flushed
( ) atrophy ( ) pain ( ) ecchymosis
( ) diaphoretic () moist
( ) problem