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OT Neonatal Screening Form

This neonatal screening form collects information about a newborn infant's general appearance, physical activity, tone, posture, level of consciousness, breathing, sensory processing, and reflexes. Key details include the child's name, mother's name, contact details, gestational age, birth weight, skin color and texture, physical movements, muscle tone, sleeping states, breathing patterns, self-soothing behaviors, eye contact, irritability, and primitive reflexes. The form aims to assess the infant's neurological functioning and development.

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ilhaam08
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127 views3 pages

OT Neonatal Screening Form

This neonatal screening form collects information about a newborn infant's general appearance, physical activity, tone, posture, level of consciousness, breathing, sensory processing, and reflexes. Key details include the child's name, mother's name, contact details, gestational age, birth weight, skin color and texture, physical movements, muscle tone, sleeping states, breathing patterns, self-soothing behaviors, eye contact, irritability, and primitive reflexes. The form aims to assess the infant's neurological functioning and development.

Uploaded by

ilhaam08
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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OT Neonatal Screening Form:

Child’s name: Mother’s name:

Contact number: Ward:

Gestational Age: Chronological Age:

Corrected Age:

Birth Weight: AGPAR score:

Medical conditions currently experienced: _______________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

General Appearance:

Skin colour and texture:

Normal Rashes Lesions/wounds Blue Jaundiced


(pink)

Physical Activity

Tracking Purposeful Grasp Head turn Bilateral


movements movements
Y  N Mid-range  Y  N Touch: Bilateral 
Smooth  Y  N
Purposeful  Unilateral
Sound:
Jerky  Y  N
Weak 
Movements
away from
midline

Tone

Low (floppy) Normal High (MAS 2- Severe (MAS


3) 4)

Posture

Supine Prone
Alignment: Symmetrical  Asymmetrical  Alignment: Symmetrical  Asymmetrical 
Limbs in flexion  extension  Head moves to side: Y N
Neck Extension Y N
Level of consciousness

State: How often:

State 1: Deep/Quiet Sleep


State 2: Light/ Active Sleep
State 3: Drowsiness
State 4: Quiet awake/Alert
State 5: Active Awake/ Alert
State 6: Crying

Breathing:

Regular 

Irregular 

Sensory Processing:

Able to self-comfort Y  N 

Normal sleep-wake cycle Y  N 

Hands on face/ mouth Y  N 

Relaxed movements Y  N 

Looks at mother Y  N 

Irritable Y  N 

Delayed bonding Y  N 

Fussing Y  N 

Looks away Y  N 

Extensor behaviours Y  N 

Finger/ toe splaying Y  N 


Reflexes:

Suck Y  N 

Root Y  N 

Moro Y  N 

Grasp Y  N 

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