Physician Newborn Examination Form

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Reproductive
Care Program
of Nova Scotia
PHYSICIAN NEWBORN EXAMINATION
(Including stillbirths)
Birth Date
Birth Time
Sex
Birth Wt. (g)
Head Circ. (cm)
Length (cm)
GESTATIONAL AGE ASSESSMENT
< 37 WEEKS (Preterm)
≥ 37 WEEKS (Term)
GESTATIONAL AGE
BREAST TISSUE
≤ 3 mm
> 3 mm
PLANTAR CREASES
Smooth, Single Crease
Covering Ant. 1/3 or More
By Dates____________ _ _ wks.
EAR
Relatively Flat, Pliable
Stiff Cartilage, Deep Crease at Outer Aspect
By Assessment________wks.
TESTES
In Canal
Well Within Scrotum
INITIAL EXAM
DISCHARGE ASSESSMENT
General – Tone, Activity, Colour
Normal
Abnormal
Discharge Weight (g) ___________________________________
Skin
Normal
Abnormal
Blood Group _______________ Direct Coombs ______________
Nutritional Status
Normal
Abnormal
Moderate Wasting
Severe Wasting
Last Total Serum Bili (mmol) __________ Date ____________
Skull Shape
Normal
Abnormal
Phototherapy
No
Yes
Fontanelle & Sutures
Normal
Abnormal
Describe:
Eyes
Normal
Abnormal
____________________________________________________
Red Reflex
Present
Absent
____________________________________________________
Ears
Normal
Abnormal
Heart
Normal
Abnormal
Nose
Normal
Abnormal
Respiratory
Normal
Abnormal
Mouth
Normal
Abnormal
Femoral Pulses
Normal
Abnormal
Palate
Normal
Abnormal
Umbilicus
Normal
Abnormal
Respiratory System
Normal
Abnormal
Tone /Activity
Normal
Abnormal
Heart
Normal
Abnormal
Normal
Abnormal
Temperature
Femoral Pulsations
Normal
Abnormal
Skin
Normal
Abnormal
Abdomen
Feeding
Breast
Exclusive
With Suppl.
Liver ( __________cm)
Normal
Abnormal
Formula _____________
Medically Indicated
Spleen ( ________cm)
Normal
Abnormal
Well Established
Umbilicus
Normal
Abnormal
Problems Ongoing
Anus
Normal
Abnormal
Genitalia
Normal
Abnormal
Neurological
Normal
Abnormal
Follow-up Plan _______________________________________
Skeletal
Clavicle
Normal
Abnormal
Hips
Normal
Abnormal
____________________________________________________
Feet
Normal
Abnormal
____________________________________________________
COMMENTS
COMMENTS
Date: ___________________
Time: _______________________
Date: _____________
Time: __________________________
Signature:________________________________________________
Signature:____________________________________________
RCP/08 – REV. 06/2012
PHYSICIAN NEWBORN EXAMINATION
WHITE- Newborn’s Chart / YELLOW- Physicians Office

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