Umbilical Cord Discharge Assessment
Please complete this form to assist with the evaluation of umbilical cord discharge in newborns. Accurate information will help ensure proper care and follow-up.
Newborn's Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent or Guardian Name
*
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Umbilical Cord Discharge Characteristics
*
Rows
Color
Odor
Amount
Discharge
Clear
Yellow
Green
Bloody
Brown
Other
None
Mild
Foul
Other
None
Small
Moderate
Large
Are any of the following symptoms present? (Select all that apply)
*
Redness around umbilical area
Swelling
Fever
Bleeding
Bad odor
None of the above
Other
Severity of Discharge (1 = Mild, 5 = Severe)
*
Mild
1
2
3
4
Severe
5
1 is Mild, 5 is Severe
Has the baby received any treatment for the discharge?
*
Yes
No
If treatment was given, please specify type and date (leave blank if none)
Additional Notes or Observations
Submit Assessment
Should be Empty: