Ferguson Adult Medical History Questionnaire

Ferguson Adult Medical History Questionnaire

Please be sure to fill out the entire form and press the "Submit" button at the end
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.
Who referred you?
What is your primary concern?
Name

First NameMiddle InitialLast Name
Age
Date of Birth

MonthDayYear
Date
Hometown
Street Address
City
State
Zip
Cell Phone
Work Phone
Email
example@example.com
Place of Employment
Highest Level of Education
Occupation/Title
Hours/Week
If not working, are you

RetiredDisabledSick LeaveOther (explain)
If you receive disability or SSI, for what disability?
and for how long?
Relationship Status
Height
Weight
Preferred Pharmacy (Name and Address)

EMERGENCY CONTACTS:
First Contact Name
Address (if different from above)
Cell Phone
Work Phone
Relation
Place of Employment
Second Contact Name
Address (if different from above)
Cell Phone
Work Phone
Relation
Place of Employment

List the names of all people currently residing in your home and provide details about each individual (age, relationship, | school/occupational status

	NAME	AGE	RELATIONSHIP	SCHOOL STATUS AND?OR OCCUPATION
1
2
3
4
5
6
7
8
9
10
11
12

List dates of moves over the past 10 years and for what reasons
How long at present address?

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

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

	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)

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)

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