MENTAL STATUS EXAMINATION
Name: _____________________________ Date: _________________
Birthday: ____________________ Age: ________
I. GENERAL DESCRIPTION
A. Appearance
Dress and Grooming Physical Characteristics Posture Gait
Meticulous Thin
Fat Straight Slow
Skilfully Applied
Normal
Garish Slump Fast
Self-neglect * Disabilities
Specify: _____________ Normal
Neat
Unconventional Voice Quality
Fashionable Strong
Weak
Hoarse
Halting
Remarks:
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B. Attitude and Interpersonal Style
Cooperative Evasive
Uncooperative * Guarded Facial Expression
Hostile * Sullen
Bland
Inappropriate Passive Flat
Boundaries * Manipulative Mobile
Seductive Contemptuous
Playful Demanding
Ingratiating Withdrawn
Remarks: _______________________________________________________________
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C. Behavior and Psychomotor Activity
Seated Quietly Motor Hyperactivity *
Hyperactive Motor Retardation *
Agitated Mannerisms and Posturing *
Combative Tension *
Awkward Severe Akathisia *
Rigid Tardive Dyskinesia *
Mannerisms Catatonic Behavior *
Posturing
Tics and Twitches
Stereotypes
Remarks: _______________________________________________________________
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D. Speech and Language
Pressured Aphasia *
Monotonous Global Aphasia (speaking, comprehension)
Emotional Broca's Aphasia (speaking)
Accented Wernicke's Aphasia (comprehension)
Impoverished Dysarthria
Neologisms * Perseveration
Stereotypy
Remarks: _______________________________________________________________
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II. EMOTIONS
A. Mood
Hopeless
Euthymic Empty
Guilty
Expansive
Irritable
Euphoric Angry
Enraged
Anxious terrified
Sullen
Depressed
Dejected
Remarks: _______________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
B. Affect
Broad Emotional Withdrawal *
Appropriate Excitement *
Constricted Full range of Affect *
Blunted *
Flat
Labile
Anhedonic
Remarks: _______________________________________________________________
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C. Neurovegative Signs of Depression
Initial Insomnia
Middle Insomnia
Terminal Insomnia
Hypersomnia
Remarks: _______________________________________________________________
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III. COGNITIVE FUNCTIONING
A. Orientation and Level of Consciousness
Lethargy Orientation
Obtundation Date
Stupor Place
Coma Identity
Remarks: _______________________________________________________________
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B. Attention and Concentration
Attention Concentration
Good Good
Poor Poor
Remarks: _______________________________________________________________
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C. Memory
Short-term Memory Anterograde Amnesia
Long-term Memory Retrograde Amnesia
Amnesia Head Injuries
Transient Global Amnesia
Remarks: _______________________________________________________________
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D. Ability to Abstract and Generalize
Proverbs
Similarities and Differences
Remarks: _______________________________________________________________
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E. Information and Intelligence
IV. THOUGHT AND PERCEPTION
A. Disordered Perceptions
Illusions Depersonalization
Hallucinations * Derealization
Remarks: _______________________________________________________________
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B. Thought Content
Thought Withdrawal Somatic Delusions
Thought Insertion Delusional Guilt
Thought Broadcast Nihilistic Delusions
Suspiciousness * Ideas of Inference
Grandiose Delusions * Ideas of Reference
Magical Thinking *
Remarks: _______________________________________________________________
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____________________________________________________________________________
C. Thought Processes
Flow of Ideas Blocking Illogical
Spontaneous Circumstantial Incoherent
Goal Directed Perseverative Neologism
Impoverished Flight of Ideas Distractible
Racing Thoughts Loose Associations Clang Association
Tangentiality
Overvalued Ideas
Conceptual
Disorganization *
Remarks: _______________________________________________________________
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D. Preoccupations
Somatic Preoccupation Compulsions
Obsessions Phobias
Remarks: _______________________________________________________________
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V. SUICIDALITY, HOMOCIDALITY AND IMPULSE CONTROL
Suicidality and Homocidality
Impulse Control
VI. INSIGHT AND JUDGEMENT
Insight
Judgement
