Ferguson Adult Medical History Questionnaire

The following questions are intended to elicit basic background information 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.

First NameMiddle InitialLast Name

Format: (000) 000-0000.

Rows	NAME	AGE	RELATIONSHIP	SCHOOL STATUS AND?OR OCCUPATION
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List all doctors and mental health professionals who have examined and/or treated you. Please give name and phone number for each.

Rows	Medication	Dose	Taken for how long?	Reason for stopping
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Rows	Medication	Dose	Taken for how long?	Reason for taking
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Rows	Name of Hospital	Year	Reason/Diagnosis
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Rows	Mother	Father	Brother(s)	Sister(s)	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
ADHD/ attentional problem
Childhood behavioral problems
Problems with aggression
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)

I do certify that all the above information is true and complete.

Ferguson Adult Medical History Questionnaire

EMERGENCY CONTACTS:

Please check those items that pertain to you

PSYCHIATRIC/PSYCHOLOGICAL/MEDICAL HISTORY

Gynecology

FAMILY MEDICAL/PSYCHIATRIC HISTORY

PSYCHOTROPIC MEDICATION LIST (for reference)