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
Age:
Gender
Date of Birth
E-mail Address
Male Female
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


 

Has the patient been treated for any of the following? (check yes or no)
Ear, Nose, Throat
Endocrine
Y N Diabetes
Y N Thyroid
Allergic
Y N Hay Fever
Y N Skin Rash
Lungs
Y N Asthma
Cardiovascular
Y N Heart
Y N Vessels
Gastrointestinal
Y N Ulcers
Y N Intestinal Problems
Y N Kidney Disease
Y N Bladder Infection
Y N Urinary Tract Infection
Skin
Y N Acne
Y N Warts
Muscles, Bones or Joints
Y N Arthritis
Y N Hyperactivity/Attention
Deficit Disorder
Y N Sinus
Y N Ear Infection
Neurological
Y N Headache
Y N Seizures
Y N Hydrocephalus
Y N Shunt
Y N Developmentally Delayed
Psychiatric
Y N Depression
Y N 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