Newborn 1) Newborn Full Name Full Name 2) DOB MM slash DD slash YYYY 3) Date MM slash DD slash YYYY 4) Nationality 5) Pediatrician Name First Last 6) Pediatrician Number7) Number of births If yes, please fill a new form8) Sex Male Female 9) Address Street Address City State / Province / Region 10) Mother's Name First Last 11) Father's Name First Last 12) Mother's Number13) Father's NumberInformation during Pregnancy14) Urinary Tract Infection (UTI) Yes No Name of medication taken 15) Female Infection (Vaginal Infection) Yes No Name of medication taken 16) Other Infection (Flu, Sinusitis, Gastro) Yes No Name of infection and medication taken 17) Hemorrhage? Yes No Week of amenorrhea 18) Corticosteroid Therapy? Yes No Name of Corticosteroid 19) Early Rupture of water pocket Yes No Week of amenorrhea 20) Regular Visit to the gynecologist Yes No 21) Folic acid before or early pregnancy Yes No 22) Did you take vitamins or iron during pregnancy? Yes No 23) Anemia during pregnancy Yes No 24) Previous Abortion? Yes No Number of abortions 25) Number of children's 26) Do you need proper information and training to care for a newborn and the need to prepare a complete room for compretensive parental care? Yes No 27) Do you need a training session and information about breastfeeding and its importance? Yes No Birth Information28) Premature Yes No 29) Week of amenorrheaPlease enter a number from 1 to 37.30) Birth weightPlease enter a number from 0 to 0.Kg31) Head circumference (HC)cm32) Birth heightPlease enter a number from 0 to 0.cm33) Mode of delivery Cesarean Normal 34) Neonatal intensive care Yes No 35) Duration in ICN 36) Early neonatal jaundice Yes No Medical Surgical History37) Allergy Yes No Allergy Type Milk Clothes Specify allergy type 38) Blood GroupFatherMotherNewborn39) Family medical history Yes No Specify medical history type 40) Surgery after birth Yes No Specify surgey 41) Skin coloring Pinkish Pale iatric Cyanosis 42) Compartmental status Calm Vigorous Flask Tamie Hypnotic 43) Nursing services needs Diet Data44) Breast feeding Yes No 45) Artificial milk Yes No ListNameQuantity each meal (ml)duration between 2 meal (h)46) Diet tolerate No Yes Vomiting Abdominal bloating Other 47) Feeding stomach tube (NG tube) Yes No Number of NG tube 48) Date of putting MM slash DD slash YYYY Home treatment : vitamin & other49) Home treatmentName & doseFrequencyTime to take Add Remove50) Facial scale
