Newborn Adaptation Assessment Form
Use this form to assess how a newborn is adjusting after birth, including feeding, sleep, elimination, comfort, and overall well-being.
Newborn & Birth Context
Newborn name or nickname
*
Date of birth
*
-
Month
-
Day
Year
Date
Age in days
Sex assigned at birth
*
Female
Male
Intersex
Prefer not to say
Gestational age at birth (weeks)
Birth setting/method
Vaginal birth
Cesarean birth
Home birth
Hospital birth
Other
Feeding & Intake Assessment
Feeding method
*
Breastfeeding
Expressed breast milk
Formula
Mixed feeding
Not yet established
Feeding frequency in the last 24 hours
*
Average feeding duration or amount per feed
Latch/suck effectiveness
*
Very poor
1
2
3
4
5
6
7
8
9
Very effective
10
1 is Very poor, 10 is Very effective
Notes on feeding difficulties
Sleep, Crying & Soothing
Average sleep duration in a 24-hour period (hours)
*
Longest sleep stretch (hours)
*
How often does the newborn cry?
*
Rarely
Sometimes
Often
Very often
How easy is it to soothe the newborn?
*
Very difficult
1
2
3
4
5
6
7
8
9
Very easy
10
1 is Very difficult, 10 is Very easy
Soothing methods used
Holding
Rocking
Swaddling
Skin-to-skin
Pacifier
Feeding
White noise
Other
Elimination, Comfort & Physical Adaptation
Number of wet diapers in the last 24 hours
*
Number of bowel movements in the last 24 hours
*
Stool appearance
*
Meconium
Transitional
Yellow/seedy
Green
Watery
Hard
Unsure
Temperature stability / warmth-coolness concerns
*
No concerns
Mild concern
Moderate concern
Severe concern
Unsure
Jaundice or yellowing noticed
*
No
Mild
Moderate
Severe
Unsure
Umbilical cord or skin concerns
Redness
Swelling
Discharge
Rash
None
Other
Caregiver Observations & Overall Assessment
Alertness and responsiveness
*
Very low
1
2
3
4
Excellent
5
1 is Very low, 5 is Excellent
Muscle tone or movement quality
1
2
3
4
5
Breathing or colour concerns
*
No concerns
Mild concerns
Moderate concerns
Urgent concerns
Comparison to expected newborn behavior
*
As expected
Somewhat different
Clearly different
Not sure
Overall adaptation rating
*
1
2
3
4
5
Other observations or concerns
Would you like a follow-up review now?
*
Yes
No
Submit Assessment
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