METRO COLLEGE OF NURSING

FORMAT FOR ASSESSMENT OF TODDLER

Identification Data
Name ..................................
Gender …………………………….........
Age: ...................
Date of Birth ......../…..../…………
Address …………………………………………………
Father’s Name………………………………………
Mother’s Name …………………………………..
Address ………………………………………………….
No. of Brother/sister ……..
Birth weight…………
Anthropometric Measurements
Anthropometry In the child Normal range
Height (cm)
Weight (kg)
Head Circumference(cm)
Chest Circumference(cm)
Mid Arm Circumference(cm)
Any significant findings

Physical Examination
Vital Signs:
 Temperature :
 Pulse:
 Respiration:
 Blood Pressure:
Physical In the child Any abnormality
Examination
Skin
Scalp
Hair
Ear
Eyes
Nose
Teeth & Gum
Throat
Bones & Joints
 Chest
Abdomen
Extremities
Genital

Mile Stones (cite examples for each development)

Physical Psycho-social and emotional Cognitive and
development development language
Gross & Fine development
Social skills Values Self-
motor skills
& esteem
behaviour
2 – 3 yrs

4 – 5 yrs

Growth & Development: Yes or No

Brushes teeth self
Washes self
Feeds self
Dresses self
Talks in sentences
Toilet control
Climb stairs
Knows full name & gender
Rids tricycle, play kind

Play habits:
 Childs favourite toy or play:
 Does he play alone or with other children?

2. Toilet training:
Trained for bowel control (if yes, at what
age):....................................................................................................................................................
..........................................................................................
Trained for bladder control (if yes, at what
age):....................................................................................
.........................................................................................................................................................
Dentition: .........................................................................................................

Behavioural Problem:
............................................................................................................................................................
...........................................................................................................................................................

Immunization:- Yes/No
Sl. Name Of At 1 2 3 4 5 I II III Remark
No. The Birth Dose Dose Dose Dose Dose Booster Booster Booster
Medicine Dose Dose Dose
1 B.C.G.
2 O.P.V.
4 D.P.T.
5 M.M.R.
6 Hepatitis B
7 T.T.
8 Others

Health History
Does the client have a past or present history of the following?
Asthma Diabetes
Attention deficit hyperactivity disorder Orthopaedic injury/ disability
Chronic or recurrent Otitis media Seizure
Congenital or acquired heart disorder Speech, hearing or visual impairment
Developmental/ learning problem Allergies
Other Somatic or psychiatric diseases specify:

Birth History
........................................................................................ ....... .............
.........................................................................................
Present Health Status
.........................................................................................
History of any Congenital Abnormality- Yes/No …………………………….
(If “yes” describe)………………………………………………………………..
…………………………………………………………………………………………….
Past Medical History ........................ ..........................
............................................................................................................................................................
Past Surgical History...................................................... ................................
...................................................................................................................................................

Family History:-
SNo Name of Relationship Age Gender Education Occupation Health Remark
Family to the client status
members

Immunization: -Yes/No
S Name of At 1 2 3 4 5 I II III Remark
No the Birt Dos Dose Dose Dose Dos Booste Booste Booste
medicin h e e r Dose r Dose r Dose
e
1 B.C.G.
2 O.P.V.
3 Vita. K
4 D.P.T.
5 M.M.R.
6 Hepatiti
s
7 T.T.
8 Others

Nutritional Status
Meal pattern at home:
Sample of a day’s meal: Daily requirements of chief nutrients:
Breakfast Lunch Dinner Snacks

Actual Wt of the child

Degree of Malnutrition = ---------------------------------X 100
Expected Wt.
 Signs of Malnutrition if Observed:-
Xerosis
Bitot’s Spot
Keratomalacia
Glossitis
Ang. Stomatitis
Bow legs
Sleep pattern
How many hours does the child sleep during day and night?
Any sleep problems observed & how it is handled:
Schooling
Does the child attend school?
If yes, which grade and report school performance?
Parent child relationship
How much time do the parents spend with the child?
Observation of parent- child interaction:
Explain parental reaction to illness and hospitalization
...........................................................................................................................................................
Child reaction to illness and hospital team
...........................................................................................................................................................
Identification of needs on priority
....................................................................................................................................................... ...
Conclusion
...........................................................................................................................................................
Health Teaching
...........................................................................................................................................................
Follow-up need
...........................................................................................................................................................
Referral
..........................................................................................................................................................
Bibliography