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Mother's Name Father's Name RPR HbsAg Bstrep
Delivery Physician Attending Physician Birth Date Discharge Date Sex Race (Check)
W B O
Gest. Age by Asses. EDC Weight Length Head Circum. Chest Abd. Apgar 1 min./5
min.
Mother's Age Grav. Para. Preg. Problem Mother Blood Infant Blood Labor (Hrs.)
Type: Type:
Membr. Rupt. Presentation Anesthesia Type Delivery Resuscitation Breast/Formula
2. Skin
(Rashes, Jaundice, Hematoma,
Cyanosis)
3. Head, Neck
(Molding, Caput, Craniotabes,
Cephalohematoma)
4. Eyes
(Abnormalities, Conjuctiva, Red
Flex)
6. Thorax
(Including Breast Hypertrophy)
7. Lungs
8. Heart
(Including Femoral Pulse)
9. Abdomen
(Including Umbilicus)
10. Genitalia
(Testes, Circumcision, Meatus,
Discharge)
11. Anus
13. Extremities
(Including clavicles and
abduction of hip joints)
14. Reflexes
(Moro, Grasp, Sucking,
Swallowing)
PATIENT IDENTIFICATION
Circumcision (If done)
Uncomplicated
Device
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