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
Date of Birth
E-mail Address
Male Female
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
Y N Diabetes
Y N Thyroid
Y N Hay Fever
Y N Skin Rash
Y N Asthma
Y N Heart
Y N Vessels
Y N Ulcers
Y N Intestinal Problems
Y N Kidney Disease
Y N Bladder Infection
Y N Urinary Tract Infection
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
Y N Headache
Y N Seizures
Y N Hydrocephalus
Y N Shunt
Y N Developmentally Delayed
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