Child Form

For persons 18 years of age or younger


Important: All text fields with a red label are required information.

Patient's Name:

last	first	middle


Birth:
Term Premature	Birth Weight	Weeks Premature

List any major illnesses or injuries, especially eye injuries:


List any operations the patient has had:


Other siblings seen by Dr. Richards or Dr. Hinrichsen:

Your Pharmacy

Please tell us if you have a preferred Pharmacy, their location and their phone number.

Has the patient been treated for any of the following? (check yes or no)

Ear, Nose, Throat

Sinus

Ear Infection

Neurological

Headache

Seizures

Hydrocephalus

Shunt

Developmentally Delayed

Psychiatric

Depression

Anxiety

Comments or other illness not listed:


	List any current medication:


	List any allergies, especially medications:


Is there a family history of any of the following? (check yes or no)
Y	N	Cataracts under age 40	Y	N	Difficulty with anesthesia
Y	N	Eye muscle problems	Y	N	Retinal problems
Y	N	Very strong glasses	Y	N	Neurological problems
Y	N	Glaucoma under age 40	Y	N	Blindness