ST. ANTHONY COLLEGE OF ROXAS CITY, INC.

San Roque Extension, Roxas City, Capiz, Philippines 5800

Member, DC-SLMES Philippines
Empowering Communities, Building Futures
+
COLLEGE OF NURSING
SY 2020-2021

HEALTH ASSESSMENT FOR NEWBORNS AND INFANTS

Biographic Data

1. Child’s Name: ________________________________________________

Nickname: _____________________________________
Parents’/Caregivers Name: _______________________________________________
_______________________________________________
_______________________________________________
2. The child’s primary health provider: ___________________________________________
The child’s last well-child care appointment: _______________________________
3. Address: _________________________________________________________________
4. Do the parents and child live in the same residence? YES ___ NO ___
Are the child’s parents:
Married? ___
Single? ___
Divorced? ___
Homosexual? ___
Who else she lives in the residence? __________________________________________
Parents’ Ages: Mother: ________________
Father: ________________
5. Child’s age: _____________
Date of Birth: ___________________

6. Is the child adopted? ___ foster? ___ natural? ___

7. Ethnic origin: ____________________________________
Religion: _______________________________________
8. Parents’ Occupation: ______________________________
______________________________

History of Present Health Concern

1. Describe the child’s general state of health.

______________________________________________________________________________
______________________________________________________________________________
___________________________________________________________________________
Does the child have chronic illness? YES ___ NO ___
2. Does the child have any allergies? YES ___ NO ___ If yes, what is the specific allergen?
____________________ How does the child react to it?
______________________________________________________________________________
3. What prescriptions, over-the-counter medications, devices and treatments and home or folk
remedies is the child taking?
 Name of the Drug Dosage Frequency Reason it is Administered

Past Health History

1. Where was the child born? _________________________________________

2. Type of delivery: _________________________________________________
Any problems during the delivery? YES ___ NO ___
Vaginal infections at time of delivery? YES ___ NO ___
3. The child’s APGAR score: _________________________________________
4. Weight: ________________
Length: ________________
Head circumference: ___________________
Any problems after birth? YES ___ NO ___ If yes, specify: __________________________
5. Past illness or injuries: _____________________________________________________
Has the child ever been hospitalized? YES ___ NO ___
Has the child ever had any major illness? YES ___ NO ___
6. Immunizations the child received this far:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________________________
Any reactions to immunizations? YES ___ NO ___
7. List any chronic health conditions in the family.

8. Does the child have family members with communicable diseases? YES ___ NO ___
 REVIEW OF SYSTEMS

GUIDE QUESTIONS

Skin, Hair, Nails

 Has your child had any changes in hair texture?
 Does your child exhibit scaling on her scalp?
 Has your child been exposed to any contagious disease such as measles,
chickenpox, lice, ringworm, scabies and the like?
 Has your child ever had any rashes or sores? Does your child have diaper
rash?
 Has your child had any excessive bruising or burns?
 Does your child have any birthmarks?

Head and Neck

 Has your child ever had a head injury?
 Did the fontanelles close on schedule? Does the child have head control? If
so, at what age did it occur?

Eyes and Vision

 Does your infant have any unusual eye movements? Does your infant/child
excessively cross eyes?
 Does your infant blink when necessary?
 Is your infant able to focus on moving objects?
 Has your infant ever had cloudiness in the eyeball?

Ears and Hearing

 Does your child appear to be paying attention when you speak? Does the
child respond to loud noise?
 Has your child had frequent ear infections? Tubes in ears?
  Does anyone in the child’s home smoke?

Mouth, Throat, Nose and Sinuses

 Does your child have any teeth?
 Does your child attend day care?

Thorax and Lungs

 Has your child ever had cough, wheezing, shortness of breath, nocturnal
dyspnea? If so, when does it occur? Has your child had frequent or severe
colds?

Heart and Neck Vessels

 Does you infant become fatigued or short of breath during feedings?

Peripheral Vascular System

 Does your child ever experience bluing of the extremities? Do your child’s
hands and/or feet get unusually cold?

Abdomen
 Are you breast or bottle feeding? What foods does the infant eat?
 Has your child ever had any excessive vomiting? Abdominal pain? Please
describe.

Genitalia
 How often does your child urinate? How many wet diapers do you change
per day?
 Is the child prone to frequent diaper rash?

Anus and Rectum

 How often does your child have bowel movement? What does it look like?
 Is there any history of bleeding, constipation, diarrhea or hemorrhoids?
Musculoskeletal System
 Has your child ever had limited range of motion, joint pain, stiffness,
paralysis?
 Has your child ever had any fractures? Have you noticed any bone
deformities?

Neurologic System
 Has your child ever had a seizure?
 Has your child ever experienced any problems with motor coordination?