Central Mindanao University

College of Nursing
PRESCHOOL ASSESSMENT FORM

A.) Demographic Data:

CHILD’S NAME: __________________ ___________________ _____________________

LAST NAME FIRST NAME MIDDLE NAME
BIRTHDATE: ____/____/______ AGE: ______ SEX: ___MALE ___FEMALE
RELIGION: __________ TYPE OF INSURANCE: ____________
GUARDIAN’S NAME: __________________________________
TYPE OF DELIVERY: _____NSVD ____C/S ___ OTHERS: SPECIFY_______
PLACE OF DELIVERY: _____HOSPITAL ____HC/BIRTHING CLINICS ____OTHERS: SPECIFY_________
ATTENDED BY: _____DOCTOR ____NURSE _____MIDWIFE _____HILOT
FAMILY HEALTH HISTORY: (Hypertension, DM, Cancer, Cerebrovascular Disease)
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NAME OF EXAMINER: ________________________ DATE EXAMINED: _________

B.) Vital Signs

Temperature: ____ Heart rate: _____ Respiratory Rate: _____

Height: ____ (cm) Weight:___ (lbs) BMI: _____ Classification:________

C.) Developmental Milestones

Erik Erikson Sigmund Freud

__Autonomy vs. Shame (Early __Anal Stage (18 months to 3

Childhood years)
11/2 – 3) __Phallic Stage (3 years to 6
__Initiative vs. Guilt (Play age 3-5) years)
__Industry vs. Inferiority (School age __Genital Stage (6 years to
5-12) puberty)
 FINE MOTOR SKILLS WITH NOT
INDEPENDENT HELP APPLICABLE
UNDRESSES SELF
STACKS TOWER OF BLOCKS
COPIES CIRCLE, CROSS, NAME WHAT HAS BEEN DRAWN
CAN DO SIMPLE BUTTONS
CAN DRAW A SIX-PART FIGURE
CAN LACE SHOES
USES SCISSORS SUCCESSFULLY TO CUT OUT PICTURE
FOLLOWING OUTLINE

GROSS MOTOR SKILLS WITH NOT

INDEPENDENT HELP APPLICABLE
RIDES TRCYCLE
GOES UP STAIRS USING ALTERNATE FEET
TRIES TO DANCE BUT BALANCE IS STILL INADEQUATE
SKIPS AND HOPS ON ONE FOOT
THROWS BALL OVERHEAD
SKIPS AND HOPS ON ALTERNATE FEET
BALANCES ON ALTERNATE FEET WITH EYES CLOSED
JUMPS FROM HEIGHT OF 12 INCHES AND LANDS ON TOES

SOCIAL AND EMOTIONAL DEVELOPMENT WITH NOT

INDEPENDENT HELP APPLICABLE
IS LESS JEALOUS OF YOUNGER SIBLING
PLAY IS ASSOCIATIVE, TRIES TO FOLLOW RULES BUT MAY
CHEAT TO AVOID LOSING
HAS IMMAGINARY PLAYMATES
DO'S AND DON'TS BECOME IMPORTANT
IS ABLE TO RUN SIMPLE ERRANDS OUTSIDE THE HOME
STRONGLY IDENTIFIES WITH PARENT OF SAME SEX,
ENJOYS ACTIVITIES SUCH AS SPORTS, COOKING, AND
SHOPPING WITH PARENT OF SAME SEX

D.) Immunization Record (INPUT THE DATE VACCINE WAS GIVEN)

BCG: ______ Rota Virus: 1. ____

HEP B: ______ 2. ____
Pentavalent/DPT: 1._____ Measles: _______
2._____ MMR: _______
E.) Health Pattern Assessment

Chief Complaint: __________________________________________

History of present illness
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Previous Hospitalizations / Surgeries: ___ Yes ___ No
Things done to manage health:
__________________________________________________________________
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Allergies: __ Yes __ No
Specify allergies: ___________________________________________

F. Medications (For Patients with Previous Hospital Admission/OPD

Consultation)
Medical Diagnosis: _________________________________________
Name Dose Schedule Indications
G.) Health Assessment ( Body Map Index)
Illustrate in the body map how your patient looks like. (e.g. Tubes inserted, Physical
abnormalities affected) Mark with a small “x” where it is located. Draw it in the body map
and then label.
Front Back

Head: Normocephalic asymmetrical enlarged masses: _____________ others:

Facial Movements: Symmetrical asymmetrical
Fontanels: closed sunken bulging

Eyes: Lids: Symmetrical R / L edema/swelling lesions: _____________

Conjunctiva: pink pale lesions discharges

Ears: External Pinnae: Normoset symmetrical tenderness lesions gross abnormalities

External Canal: discharge: ___foul smelling ___serous ___purulent ___mucoid impacted cerumen
Gross Hearing: normal decreased R / L deafness

Nose: alar flaring

Septum: midline deviated perforated
Mucosa: pinkish pale reddish Discharge: serous mucoid purulent bloody
Patency: both patent R / L obstruction masses/lesions: describe ____________________
Gross Smell: normal/symmetrical R / L olfactory deficiency

Mouth: Lips: pinkish pallor cyanosis dryness/cracks

 Mucosa: pinkish pallor cyanosis
Tongue: midline R / L deviation atrophy fasciculation
Teeth: complete missing teeth caries
Gums: pinkish pallor bleeding tenderness

Skin: General Color: pinkish pallor jaundice cyanotic flushed

Texture: smooth rough
Turgor: Supple firm dehydrated others: ___________________________
Temperature: warm cool others: ___________ Moisture: dry moist/clammy oily
Others: petechaie ecchymosis hematoma lesions/ rashes: ________________________
Edema: ___pitting ___non-pitting

Back and Extremities: Range of Motion: full symmetrical decreased ROM (specify joint)__________
Joint tenderness/pain joint swelling at ____________ varicose veins deformities_________
Muscle tone and Strength: equally strong symmetrical in size
R / L Upper / Lower Paresis R / L Upper / Lower Paralysis
Spine: midline Kyphosis Lordosis Scoliosis
Gait: coordinated smooth uncoordinated