College

of Nursing and Allied Health Sciences

Nursing Department
COMMUNITY HEALTH NURSING

Child assessment sheet ( Record )

Student name………………………… Group no …………………………

Level ……………………………………… no; of student…………………………
Date…………………………………..

Personal History
1. Child's name:---------------------------------
2. Address:--------------------------------------

3. Age: ------------------------------------------
4. sex:-------------------------------------------
5. Reason for visit ------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------
Types of feeding:
§ Breast ( ) § Bottle ( )

§ Mixed ( ) § Normal diet ( )

Vaccination received:
Vaccines Age
1- B.C.G
2- Polio Sabine
3- DPT
4- Viral hepatitis
5- Measles
6- MMR
7- Booster dose
8- Other:

History of communicable diseases:

1- Whooping cough ( ) 2- Mumps ( ) 3- T.B ( )
4- Measles ( ) 5-Poliomyelitis ( ) 6-Meningitis ( )
7- Hepatitis ( ) 8- Others ------------------------------------------

History of other medical problems:

§ Allergy ( ) 3- Asthma ( )

١
§ Recurrent attack of fever ( )
§ Urine: Frequency ( ) Oder( ) Color( )

§ Bowel Condition: Frequency ( ) Oder( ) Color( )

Presence of blood ( ) Mucus ( )
§ Diarrhea: Frequency of attack\ day ( ) Duration ( )
Severity( ) Oder ( )
- Others ---------------------------------
Physical Examination:
§ General appearance: - Pallor ( ) - Jaundice ( )
-Cyanosis ( ) - Conscious ( )
§ Vital signs: -T( ) -P( ) -R( ) -BL.P( )
§ Body Parameters: Wt. ------------- Ht.----------------- H.C.---------------
§ Body Mass Index: -----------------------------------
§ Ant. Fontanel ----------------------------- post. Fontanel------------------------------
§ Eye --------------------------------------------------------------------------------------------------
§ Mouth: - Cleft lips( ) Cleft palate( ) Dry lips ( )
§ Teething: ------------------------------------------------------------------------------
§ Neck -----------------------------------------------------------------------------------------------
§ Chest -----------------------------------------------------------------------------------------------
§ Heart -----------------------------------------------------------------------------------------------
§ Abdomen -----------------------------------------------------------------------------------------
Present complains:
§ Complains:
§ Onset:
§ Duration:
§ Factors that increase or decrease the symptoms:
§ Treatment:

Investigation:
§ Thyriod test:
§ Urine:
§ Blood:
§ Others: