AGE

CLINICAL RECORDMOTHER'S LAST NAME - FIRST NAME - MIDDLE NAME

METHOD OF DELIVERY

GEN. APPEARANCE FACIES BIRTH WEIGHT TEMPERATURE CHARACTER OF CRY

BREATHING CYANOSIS SKIN VERNIX SUBCUT. TISSUE PALLOR ICTERUS

HEAD FONTANELLES SUTURES EYES EARS NOSE MOUTH

ABDOMEN LIVER SPLEEN CORD GENITALS ANUS MECONIUM

SPINE EXTREMITIES MUSCLE TONE PARALYSES REFLEXES MORO JOINTS

SEX RACE

REGISTER NO. WARD NO.

THROAT NECK CHEST LUNGS HEART MURMURS

RESUSCITATION USED (Type) SUCTION USED (Type)CHARACTER OF CRY

PRENATAL CARE BY (Name of Physician)

PRENATAL COURSE: (Include illnesses, contacts with diseases. Details under remarks)

ANALGESIA (State whether scopolamine, barbiturate or opiate; dosage and hours of administration)

REMARKS (Summary of complications, etc., of pregnancy and birth, and nature of therapy)

SEROLOGY-TREATMENT IF POSITIVE

INFANT'S CONDITION AT BIRTH

EYE PROPHYLAXIS (State type)

RESPIRATORY STIMULANT USED (Type)

COMPLICATIONS OF DELIVERY

ANESTHESIA (Length of adminis- tration, kind, and amount)

VIT. K

HRS. MIN.

MIN.

RESPIRATION NORMAL IN

INITIAL PHYSICAL EXAMINATION

NEWBORN Standard Form 535

PRESCRIBED BY GSA/ICMR 41 CFR 201-45-505 OCTOBER 1975

PATIENT'S IDENTIFICATION (For typed or written entries give: Name-last, first, middle; grade; date; hospital or medical facility)

To be completed within twenty-four hours of birth: Note especially sutures, hemorrhage, clavicles, cephalhematoma, fontanelles, cleft palate, heart rate and rhythm, anus, skin blemishes, jaundice, sternocleidomastoid, umbilicus, hernia, clubfeet, fingers, tumors, mongolism, character of cry, other deformities. Use progress sheet for abnormalities, description, and elaboration.

OXYGEN IN DELIVERY ROOM DURATION

MEASUREMENTS:

MIN.

EXPECTED DATE OF CONFINEMENT

DATE OF BIRTH

DATE

FATHER'S LAST NAME - FIRST NAME - MIDDLE NAMERACE

LENGTH HEAD CHEST ABDOMEN

REGISTER NO.

GRAVIDA PARA ANTI Rh

RhSTILLBIRTHS LIVING CHILDREN

LAST MENSTRUAL PERIOD

MOTHER'S BLOOD GROUP

FATHER'S RhABORTIONS

MOTHER'S HEALTH PRIOR TO PREGNANCY

PAST TRANSFUSION HISTORY

ABNORMALITIES OF PREVIOUS PREGNANCIES

AGE

NEWBORN

LENGTH OF FIRST STAGE

HRS.

HRS.

MIN.

LENGTH OF SECOND STAGE

RESPIRATION ESTABLISHED IN

YES NO

SIGNATURE OF OBSTETRICIAN

ABNORMAL FINDINGS ON PHYSICAL EXAMINATION:

SIGNATURE OF PHYSICIAN DATE

TIME

CONDITION ON DISCHARGE: (Record any significant physical findings and summarize any unusual observations or therapy during hospitalization)

DISCHARGE FEEDING: (Use progress notes to record unusual feeding behavior)

FOLLOW-UP

REFERRED TO

BREAST

BREAST AND COMPLEMENT

NURSING VISIT ORDERED

OFFICE OF PRIVATE PHYSICIAN

FORMULA

(Amount) (Number of feedings)

(Location)(Date)

REFERRED TO CLINIC

(Location)

SOCIAL SERVICE FOLLOW-UP ADVISED.

(Name of social service agency)

(Date)

SPECIFY FORMULA

SIGNATURE OF PHYSICIAN DATE OF DISCHARGE WEIGHT ON DISCHARGE

PROGRESS NOTES (Sign and date all notes)

STANDARD FORM 535 OCTOBER 1975 BACK