Escolar Documentos
Profissional Documentos
Cultura Documentos
Subject ID number:
VITAL SIGNS
____________ ____________
Weight (record in lbs) Head Circumference (record in cm) Height (record in cm)
HEAD
Abnormality Noted
Abnormal head shape
No
Yes
Not Examined
Brachycephaly Dolicocephaly Trigonocephaly Post. Midline Scalp Defect(s)
Hypertelorism / Hypotelorism Microphthalmia Epicanthal folds Slanted Palpebral fissures Shallow orbital ridges Prominent superior-orbit ridge Prominent Eyes Abnormal Red Reflex
Simple ears (lack of usual fold of helix) Serous Otitis R/C Acute Otitis R/C PE Tubes
NOSE
Abnormality Noted
No
Yes
Not Examined
Bulbous tip of nose Nasal Salute Nasal Discharge Turbinate Pallor/ Edema
Low Nasal Bridge Prominent Nasal Bridge Broad Nasal Bridge Small / short nose Upturned nose
FACE
Abnormality Noted
Midface hypoplasia Long Narrow Facies
No
Yes
Not Examined
Micrognathia Prognathia
No
Yes
Not Examined
Micro or macrostomia Oral frenula Cleft/irregular tongue Macroglossia / Microglossia Tonsil Hypertrophy Tonsil Inflammation
Bifid Uvula High-arched palate Abnormal philtrum Cleft lip / palate Prominent or thin lips Lip pits Down-turned corners of mouth
TEETH
Abnormality Noted
No
Yes
Not Examined
Dental Cupping Prominent Central Incisors Dental Flattening (from bruxism)
SPINE
Abnormality Noted
Scoliosis Kyphosis
No
Yes
Not Examined
Lordosis Deep sacral dimple or sinus
NECK
Abnormality Noted
Web neck Short neck Thyroidmegaly
No
Yes
Not Examined
Redundant neck skin Torticollis
TORSO
Abnormality Noted
Abnormal nipples Hypoplastic clavicles Pectus carinatum
No
Yes
Not Examined
Short sternum Shield chest Pectus excavatum
Short arms proximal, distal or proportionate Radial hypoplasia Radial- ulnar synostosis Short/small or long/large hands Metacarpal hypoplasia (short metacarpals) Thumb hypoplasia
JOINTS
Abnormality Noted
No
Yes
Not Examined
Hypermobile / ligamentous laxity
No
Yes
Not Examined
Hypoplastic nails Broad first toes/toenails Overlapping toes Equinovarus feet Pes Planus
Short legs proximal, distal or proportionate Patellar dysplasia Short/small or long feet Short metatarsals 2,3 metatarsals syndactyly Syndactyly other
Yes No
Woods Lamp Exam Abnormal Unusual Skin (loose, thick, elastic) Rash Bruising, abrasions, calluses Dry skin, ecrema Caf-au-lait #___________ Axilary/ inguinal freckling Ash-leaf spots #__________ Other hyper/hypopigmentation Neurofibromas
RESPIRATORY
Abnormality Noted
No
Yes
Not Examined
CARDIOVASCULAR
Abnormality Noted
Irregular rhythm Cyanosis or pallor Murmur
No
Yes
Not Examined
No
Yes
Not Examined
Splenomegaly / Hepatomegaly Hernias (Umbilical and inguinal) Abdominal mass Abdominal distention
GENITOURINARY
Abnormality Noted
Hypospadias Micropenis (small) Cryptorchidism Abnormal scrotum
No
Yes
Not Examined
No
Yes
Facial symmetry Palate motion Tongue bulk Tongue motion Shoulder shrug
Normal Abnormal Normal Abnormal Not Examined Not Examined Symmetrical Asymmetrical Not Examined Normal Normal Normal Abnormal Abnormal Abnormal Not Examined Not Examined Not Examined
MUSCLE BULK
Abnormality Noted
No
Yes
Not Examined
Upper RIGHT
Proximal Distal Proximal Distal
Lower LEFT
Proximal Distal Proximal Distal
Lower RIGHT
Proximal Distal Proximal Distal
MUSCLE STRENGTH Abnormality noted in limbs No Yes If yes, please specify ( all, if global weakness)
Upper LEFT
Proximal Distal
Not Examined
Upper RIGHT
Proximal Distal
Lower LEFT
Proximal Distal
Lower RIGHT
Proximal Distal
No No
Yes Yes
Upper RIGHT
Proximal Distal Proximal Distal
Lower LEFT
Proximal Distal Proximal Distal
Lower RIGHT
Proximal Distal Proximal Distal
No
Yes
Not Examined
Yes
Not Examined
NIMH PDN draft 7.25.06 Adapted from ATN
Physical Exam / Neurologic Evaluation
No No No No No No No
Not Examined Not Examined Not Examined Not Examined Not Examined Not Examined Not Examined
No
Yes
Not Examined
Not Examined Not Examined Not Examined Not Examined Not Examined Not Examined Not Examined Not Examined Not Examined
SENSORY
Abnormality Noted
No
Yes
Not Examined
Lower LEFT
Proximal Distal
Lower RIGHT
Proximal Distal
Light Touch
Proximal Distal
REFLEXES
Abnormality Noted
Right
No
Yes
Not Examined
Left
0 0 0 0 0
1 1 1 1 1
2 2 2 2 2
3 3 3 3 3
4 4 4 4 4
NX NX NX NX NX
0 0 0 0 0
1 1 1 1 1
2 2 2 2 2
3 3 3 3 3
4 4 4 4 4
NX NX NX NX NX
Pathological Reflexes
Babinski (Plantar extensor) Present Absent NX Present Absent NX
COORDINATION
Dysmetria
Abnormality Noted
Present
No
Absent
Yes
NX
Not Examined
Present Absent NX
Abnormality Noted
Present Present Present Present Present Present
No
Yes
Absent Absent Absent Absent Absent Absent
Not Examined
Not Examined Not Examined Not Examined Not Examined Not Examined Not Examined