Today's Weight_____ grams (_____ lbs. _____ounces)

Length _____ cm (_____inches)

Head Circumference _____ cm (_____ inches)

Chest Circumference _____ cm (_____ inches)

Feeding: Breast __ Formula __ Type of Formula_________________

Vital Signs: Temperature_____ Apical Pulse_____ Respirations_____

Stimulus Responses: Spontaneous__ Tactile__ To sound__ Unresponsive__

Reflexes: Moro (startle)__ Grasp__ Suck__ Rooting __

Cry: Strong__ Shrill__ Weak__

Muscle tone: Full ROM__ MAE equally__ Hypotonic__ Hypertonic__ Jittery__ Other__

Activity: Fussy__ Sleeping__ Quiet__ Alert__

Fontanel: Soft__ Flat__ Closed__ Tense__ Bulging__ Depressed__ Full__

Sutures: Approximated__ Overriding__ Separated__

Eyes: Swollen__ Drainage__

Nares: Stuffy__ Drainage__ Palate not intact__

Cardia Rhythm: regular__ irregular__ Peripheral pulses: present__ palpable__

Murmur: Soft__ Loud__ Intermittent__ Weak__ Full__ Bounding__ Active pre cordium__

Capillary Refill: 2-3 seconds__ 3-4 seconds__ >5 seconds__

Edema: Periorbital__ Generalized__ L Foot__ R Foot__

Respirations: Regular__ Irregular__ Periodic__

Breath sounds: Equal__ Clear__ Unequal__ Diminished__ Course__ Moist__ Rales__ Rhonchi__ Nasal Flaring__ Air exchange: Good__ Poor__ Fair__

Retractions: None__ Mild__ Moderate__ Severe__

Abdomen: Soft__ Firm__ Flat__ Round__ Full__ Distended__ Tense__ Visible loops__ Flatus__

Bowel sounds: Normoactive__ Hyperactive__ Hypoactive__ Absent__

Umbilicus: 3 vessel cord__ 2 vessel cord__ Odor__ Moist__ Dry__

Umbilical Clamp in place__ or Removed @_________

Anus: Perforate__ Imperforate__

Bladder: Nondistended__ Distended__ Voiding__ Voiding how often__ # of diaper changes__

Genitals: Genitals WNL__ Ambiguous genitals__ Vaginal skin tag__

Testicles: Descended__ One undescended__ Two undescended__ Hydrocele__

Skin Color: Flesh tone__ Pale__ Cyanotic__ Ruddy__ Flushed__ Jaundice__ Mottled__

Skin Temperature: Warm__ Hot__ Cool__

Mucous Membranes: Pink__ Moist__ Dry__ Lesions__

Skin Condition: Intact__ Dry__ Intact__ Moist__ Rash__ Bruises__ Petechiae__Forceps marks__

Purpura__ Lesions__ Abrasions__ Acrocyanois

Spine: Normal__ Abnormal__ Describe____________________________

Extremities: Equal__ Able to move all extremities__ Unequal extremities__

Limited ROM: L Arm__ L Leg__ R Arm__ R Leg__

Hips: Normal__ Abnormal__ Describe_____________________________

Helpful Hints:

Calculating Meds: 2.2 Lbs. = 1 kg

Weighing wet diapers: 1 g = 1cc