Name:No. □□ -□□□□□□□□□
gender
0 unknown sex 1 male 2 female□
9 Sex not specified
date of birth
□□□□ □□ □□
identifier
Identification address
father
(full name)
occupation
Contact number
date of birth
mother
(full name)
occupation
Contact number
date of birth
Birth gestational age
Maternal morbidity during pregnancy 1 diabetes 2 pregnancy-induced hypertension 3 others □
Name of midwifery institution
Birth situation 1 natural delivery 2 attraction 3 forceps 4 splitting 5 multiple births 6 breech position 7 others □ /□
Neonatal asphyxia 1 No 2 (mild to moderate) □
Is there any deformity 1 No 2 Yes □
Neonatal hearing screening 1 passed 2 failed 3 failed screening □
Neonatal birth weight kg
Birth length is cm.
Feeding mode 1 pure breast milk 2 mixed with 3 labor □
temperature
Respiratory frequency/minute
Pulse rate/minute
Skin color 1 ruddy 2 yellow 3 other □□□□□
Front chimney cm* cm 1 normal 2 protruding 3 concave 4 other □
1.2 No abnormality was found in eyes □
There is no abnormality in the range of motion of 65438 0 □.
No abnormality is found in the ear 1.2 abnormality □
Neck mass 1 none 2 yes □
No abnormality is found in the nose 1.2 abnormality □
No abnormality was found in skin 1; 2 Eczema 3 Erosion 4 Others □ /□
No abnormality is found in oral cavity 1.2 abnormality □
No abnormality was found in anus 1.2 abnormality □
Cardiopulmonary 1 No abnormality was found. 2 Abnormal □
No abnormality is found in external genitalia 1.2 abnormality □
No abnormality is found in abdomen 1.2 abnormality □
Spine 1 No abnormality is found □
Umbilical cord 1 did not fall off, 2 fell off, 3 oozed from umbilical region, and the remaining 4 □
Referral 1, 2 cases, none □
Reason:
Institutions and departments:
Guidance 1 feeding guidance 2 breastfeeding 3 nursing guidance 4 disease prevention guidance □/□ /□
The date of this visit is year month day.
Next follow-up location
Next Follow-up Date Month Year Month Day
Signature of follow-up doctor
/kloc-health examination records of children under 0/year old
Name:No. □□ -□□□□□□□□□
project
Full moon; The baby is one month old.
Three months old
6 months old
Eight months old
Subsequent date
Weight (kg)
Zhongshangxia
Zhongshangxia
Zhongshangxia
Zhongshangxia
Body length (cm)
Zhongshangxia
Zhongshangxia
Zhongshangxia
Zhongshangxia
body
style
check
cheque
Face 1 ruddy 2 yellow dye 3 others
□
□
□
□
Skin 1 No abnormality is found. Pervert 2.
□
□
□
□
Front chimney 1 closed
2 patent cm * cm
□
centimetre
□
centimetre
□
centimetre
□
centimetre
1 No abnormality was found in the eye 2.
□
□
□
□
Ear 1 No abnormality found 2.
□
□
□
□
Number of teeth (1)
————
Cardiopulmonary 1 No abnormality was found. Pervert 2.
□
□
□
□
Abdomen 1 No abnormality is found.
□
□
□
□
Umbilical cord area 1 No abnormality found 2.
□
□
□
□
No abnormality is found in limbs 1.
□
□
□
□
Rickets symptoms
1 No 2 night terrors, 3 hyperhidrosis and 4 irritability.
————
□/□/□
□/□/□
□/□/□
Signs of rickets
1 2 Osteomalacia, 3 square skull and 4 occipital baldness
5 Rib bead 6 rib eversion 7 rib cartilage groove 8 chicken breast 9 bracelet logo 10 "O "leg 1 1 "X" leg
————
□/□/□/□/□/□/□/□/□/□
□/□/□/□/□/□/□/□/□/□
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Anal/external genitalia
1 No abnormality found.
□
□
□
————
Hemoglobin value (g/L)
————
————
Outdoor activities (hours/day)
Take vitamin d (international unit/day)
————
Development assessment 1 passed 2 but failed.
□
□
□
□
Diseases between follow-up visits
1 not sick 2 sick
□
□
□
□
other
Transfer the patient to another medical institution for treatment.
1 Yes 2 No□
Reason:
Institutions and departments
1 Yes 2 No□
Reason:
Institutions and departments
1 Yes 2 No□
Reason:
Institutions and departments
1 Yes 2 No□
Reason:
Institutions and departments
guide
1 feeding instruction
2 Breastfeeding
3 disease prevention
1 feeding instruction
2 Breastfeeding
3 disease prevention
1 feeding instruction
2 Breastfeeding
3 disease prevention
1 feeding instruction
2 accident prevention
3 disease prevention
Next follow-up date
Signature of follow-up doctor
1~2 years old children's health examination record form
Name:No. □□ -□□□□□□□□□
project
12 months old
18 months old
24 months old
30 months old
Subsequent date
Weight (kg)
Zhongshangxia
Zhongshangxia
Zhongshangxia
Zhongshangxia
Body length (cm)
Zhongshangxia
Zhongshangxia
Zhongshangxia
Zhongshangxia
body
style
check
cheque
Face 1 ruddy 2 yellow dye 3 others
□
□
□
□
Skin 1 No abnormality is found. Pervert 2.
□
————
————
————
Front chimney 1 closed
2 patent cm * cm
□
centimetre
□
centimetre
————
————
1 No abnormality was found in the eye 2.
□
□
□
□
Ear 1 No abnormality found 2.
□
□
□
□
Number of teeth (1)
Cardiopulmonary 1 No abnormality was found. Pervert 2.
□
□
□
□
Abdomen 1 No abnormality is found.
□
□
□
□
No abnormality is found in limbs 1.
□
□
□
□
Gait 1 No abnormality is found. Pervert 2.
————
□
□
□
Signs of rickets
1 2 Osteomalacia, 3 square skull and 4 occipital baldness
5 Rib bead 6 rib eversion 7 rib cartilage groove 8 chicken breast 9 bracelet logo 10 "O "leg 1 1 "X" leg
□/□/□/□/□/□/□/□/□/□
□/□/□/□/□/□/□/□/□/□
□/□/□/□/□/□/□/□/□/□
□/□/□/□/□/□/□/□/□/□
Hemoglobin value (g/L)
Outdoor activities (hours/day)
Take vitamin d (international unit/day)
□
□
□
Development assessment 1 passed 2 but failed.
Diseases between follow-up visits
1 not sick 2 sick
□
□
□
□
other
Transfer the patient to another medical institution for treatment.
1 Yes 2 No□
Reason:
Institutions and departments
1 Yes 2 No□
Reason:
Institutions and departments
1 Yes 2 No□
Reason:
Institutions and departments
1 Yes 2 No□
Reason:
Institutions and departments
guide
1 feeding instruction
2 Accidental injury
3 disease prevention
1 feeding instruction
2 Accidental injury
3 disease prevention
1 feeding instruction
2 Accidental injury
3 disease prevention
1 feeding instruction
2 Accidental injury
3 disease prevention
Next follow-up date
Signature of follow-up doctor
3-year-old children's health examination record form
Name:No. □□ -□□□□□□□□□
Subsequent date
date month year
Physical development
Weight g (up, middle and down)
Length cm (top, middle and bottom)
Physical development assessment
1 normal 2 low weight 3 emaciation 4 stunting 5 obesity
physical examination
Face □
1 ruddy 2 abnormal
Gait □
1 normal 2 abnormal
eye
1 normal 2 abnormal
ear
1 normal 2 abnormal
Cardiopulmonary □
1 normal 2 abnormal
Liver and spleen □
1 normal 2 abnormal
Development evaluation
Behavior □
1 failed to pass 2.
Socialization □
1 failed to pass 2.
initial stage
disease
1 2 pneumonia, 3 measles, 4 anemia, 5 malnutrition, 6 rickets, 7 diarrhea hospitalization, 8 trauma hospitalization, 9 others.
□/□/□/□/□/□/□/□
allergic history
1 No 2 is □
other
Transfer the patient to another medical institution for treatment.
1 No 2 is □
Reason:
Institutions and departments:
guide
1 Dietary Guidance 2 Prevention of Accidental Injury 3 Disease Prevention□ /□ /□
Signature of follow-up doctor