Ferguson Child and Adolescent Medical History Questionnaire

Ferguson Child and Adolescent Medical History Questionnaire

Please be sure to fill out the entire form and press the "Submit" button at the end
Please complete the following form about your child to the best of your knowledge. These questions are intended to elicit basic background information about your child and your family prior to our first visit. Much of this information will be discussed in greater detail during your appointment. Please leave questions blank if they do not pertain to you or if you do not feel comfortable answering.
Who referred your child?
What was their concern?
What is your primary concern?
What is the school’s primary concern? (if applicable)
When did you first become aware of these concerns?
Name of Child

First NameMiddle NameLast Name
Street Address
City
State
Zip
Phone #
Email (best address for office contact)
example@example.com
Age
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Place of Birth
Height
Weight
Preferred Pharmacy (Name and Address)
Who has legal custody or guardianship of the child?
(Please be prepared to provide supporting documentation of custody/guardianship/medical decision making at first visit, if applicable)

FAMILY INFORMATION
FATHER:
Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address (if different from above)
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email
example@example.com
Place Of Employment
Title
Highest Level of Education
MOTHER:
Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address (if different from above)
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email
example@example.com
Place Of Employment
Title
Highest Level of Education
STEPMOTHER:
Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address (if different from above)
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email
example@example.com
Place Of Employment
Title
Highest Level of Education
STEPFATHER:
Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address (if different from above)
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email
example@example.com
Place of Employment
Title
Highest Level of Education
Please provide marital history (including dates of all marriages, divorces, and remarriages) for parents and stepparents.

List the names of all siblings, including stepbrothers and sisters, half brothers and sisters, and any miscarriages or stillbirths. Also give a brief description of each child age, relationship, school status

Rows	NAME	AGE	RELATIONSHIP	SCHOOL STATUS AND/OR OCCUPATION
1
2
3
4
5
6
7
8
9
10
11

Does anyone who lives in the home smoke cigarettes?
List dates of moves and for what reasons.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How long at present address?

DEVELOPMENTAL INFORMATION
Length of Pregnancy in weeks
Birth Weight (lbs)
Birth Weight (oz)
Planned or unplanned pregnancy
Was the pregnancy complicated or involved with drugs or alcohol?
Nature of delivery
Condition of child at time of birth
At what age was child adopted?
Age of Father at time of birth or adoption
Age of Mother at time of birth or adoption
Please give age your child: Walked
Please give age your child: Talked
Please give age your child: Toilet trained
Has your child ever been exposed to abuse? If comfortable, please state whether it is/was physical, emotionalor sexual and whether he/she was the object of the abuse or exposed to it.
Please list any additional stressors or traumas for the family and child
Current School
Grade
Teacher(s)
Teacher Contact Information (phone and/or email)

List, in order of attendance, all school enrollments your child has had. Give name and city/state. Indicate if it was a public or private school and the grade attended.

Rows	School	City/State	Public/Private	Grade(s)Attended	Average Grade (A-F)
1
2
3
4
5
6

Have any grades been repeated?
Has your child been given a diagnosis of a learning disability? By whom?
Has your child been identified for special education, learning support, or emotional support? Please state year identified and describe provisions made.

Rows	Medication	Dose	Taken for how long?	Reason for stopping
1
2
3
4
5
6
7
8

Rows	Medication	Dose	Taken for how long?	Reason for taking
1
2
3
4
5
6
7
8

Rows	Child’s Mother	Child’s Father	Child’s Brother(s)	Child’s Sister(s)	Child’s Maternal Grandma	Child’s Maternal Grandpa	Child’s Paternal Grandma	Child’s Paternal Grandpa
Childhood behavior problems
Problems with aggression
ADHD/ Attentional problem
Learning disability
Failed high school
Intellectual Disability
Autism
Psychosis/schizophrenia
Bipolar Disorder
Depression (greater than 2 weeks)
Suicide
Anxiety or adjustment disorder
Panic disorder
Other mental disorder (describe below)
Tic disorder or Tourette’s
Heart Problem at a young age (<60)
Alcohol Abuse
Substance Abuse
Antisocial behavior (assault/thefts)
Arrests/incarcerations
Physical abuse (victim)
Physical abuse (perpetrator)
Sexual abuse (victim)
Sexual abuse (perpetrator)

Ferguson Child and Adolescent Medical History Questionnaire

FAMILY INFORMATION

FATHER:

MOTHER:

STEPMOTHER:

STEPFATHER:

DEVELOPMENTAL INFORMATION

PSYCHIATRIC/PSYCHOLOGICAL/MEDICAL HISTORY

Gynecology

Family Medical/Psychiatric History

PSYCHOTROPIC MEDICATION LIST (for reference)

Rows	Name of Hospital	Year	Reason/Diagnosis
1
2
3
4
5