Newborn Initial Assessment Form
Please complete all sections to record the initial assessment of the newborn.
Date and Time of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Newborn's Full Name
*
First Name
Last Name
Sex of Newborn
*
Male
Female
Ambiguous/Other
Gestational Age (weeks)
*
Birth Weight (grams)
*
Length (cm)
*
Head Circumference (cm)
*
Apgar Scores at 1 and 5 Minutes
*
Rows
1 Minute
5 Minutes
Appearance (Color)
Pulse (Heart Rate)
Grimace (Reflex Irritability)
Activity (Muscle Tone)
Respiration
Physical Examination Findings
*
Rows
Normal
Abnormal
Comments
General Appearance
1
2
Skin
3
4
Head/Neck
5
6
Chest/Lungs
7
8
Heart
9
10
Abdomen
11
12
Genitalia/Anus
13
14
Extremities
15
16
Neurological
17
18
Feeding Status
*
Breastfeeding
Formula Feeding
Not yet fed
Other
Any Immediate Interventions Required?
*
None
Oxygen
Suction
Resuscitation
Other
Additional Notes or Observations
Assessor's Full Name
*
First Name
Last Name
Submit Assessment
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