ADMISSION WORKSHEET

HPI:                                                                                                     Pt Name:
                                                                                                         DOB:       /   /        (Age:            )

                                                                                                         Phone #:

                                                                                                         ALL: NKDA No latex all.
In ED:
                                                                                                         IMM: UTD

                                                                                                         NUTRITION: Breast Bottle

PMH:                                                                              SH: Lives with:
                                                                                  School:                                               Grade:
                                                                                  Performance:             Friends:

                                                                                                   Smokers in house Pets   Carpet   Dust/mites
BIRTH HX: FT NSVD                No abx (mom GBS -)          No NICU          Sick contacts:
APGAR: 1/ 5
                                                                                  FH: Unremarkable

Prenatal care started at ______ wks. AFP/triple scr/amnio nl No DM No STD’s
No substance use Mom’s bld type: ____ Pt’s bld type: ____ RhoGAM to mom
DEVELOP HX: Met all milestones                                 ROS: Fatigue Appetite/ Wt gain/loss Fussy Fever Hot/cold
                                                                Muscle/joint pain Skin/hair/nail ’s Rash/skin lesions Jaundice
                                                                HA Vision ’s Glasses Hearing problems Earache/pulling
                    E.I.     SpEd      Residential school    Congestion Runny nose Cough Sore throat Swollen glands
                                                                Frequent colds/illness Teething CP SOB Wheezing Cyanosis
                                                                Abd pain N/V Blood/mucous/bile in vomitus Diarrhea Constipation
                                                                Blood/mucous/bile in stool Hematuria Dysuria Frequency/urgency
                                                                Polyuria Anuria Menstrual problems Depression Behavioral ’s
                                                                Gait/balance problems Numbness/tingling Tics Seizures LOC
Tm in ED:          Tc:           HR:         BP:          /             RR:     O2sat:         % on         I/O in ED:             /
Ht:         cm (         %ile)         Wt:        kg (   %ile)      BMI/Wt for Ht:         (     %ile)      HC :          cm (         %ile)
GEN: WD/WN NAD Crying Sleeping Awake/alert Agitated

SKIN: No rashes/petichiae No bruises/lesions No jaundice No cyanosis Nl turgor Not dry/scaly Not diaphoretic
No malformations noted No scars Birthmarks:

HEENT:  NC/AT AOFF PERRL EOMI No strabismus No ptosis  No scleral icterus  RR + bilat Fundi nl
       TM’s not red/bulging Nares clear OP clear/ non-eryth No palatal petichiae MMM No dental caries
       1/2 tooth eruption nl for age:

NECK: Supple Nl ROM No LAD No cysts Thyroid not enlarged/no nodules

CV: RRR         S1&S2 nl         Nl S2 split     No M/R/G 2+ radial 2+ carotid 2+ femoral 2+ DP’s Cap ref < 2s UEs/LEs

PULM: CTA/P bilat No stridor/upper airway sounds No wheezes No crackles No grunting/flaring/retractions
      Nl chest contour Peak flows:       /     /   (predicted =   )

ABD: Soft NT ND BS nl throughout Liver ___ fingerbreadths below costal margin
     No heptomegaly No splenomegaly No hernias

EXT: WWP bilat No lesions/nodules No cyanosis No clubbing No edema No muscle atrophy Nl ROM
     Barlow/Ortoloni normal

BACK: Spine straight No tufts or dimples No CVA tenderness

GU/RECTAL: Normal ♀ Normal ♂ Testes  No hernias Tanner I / II / III / IV / V Nl sphincter tone Guiac negative

NEURO: Sleeping Alert Regards face Fixes/follows  Moving all extremities Primitive reflexes intact
       CN II-XII intact 5/5 strength throughout Light touch intact throughout Normal gait
       Gross motor intact for age Fine motor intact for age Cognitive intact for age Language intact for age

PSYCH: Social skills appropriate for age Affect normal Crying but consolable Parent(s) appropriate

                                                              MCV   Retic                             AST          U/A:    Cath Bag Cl ctch
                                                                                                      ALT                  pH =
                                                                                                      T. Bili              SG = 1.
                                                                                                      Dir                  Gluc         RBC
            AG =                             P       L   M     E    B     Bnd            ANC =        A                   Ket          WBC
                                                                                                      Amy                  Bld          Epi
ABG:   /     /     /       on     % FiO2
                                                                                                      Lip                  Prot         Bact
CSF: Prot    Glu    WBC RBC      G.S.:                                                                Alb                  Nit          Casts
Cx’s sent: Blood (x ) Urine (cath) CSF                    Sputum                                                      LE

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