SINA INSTITUTE OF NURSING AND ALLIED HEALTH SCIENCES QUETTA
DOCTOR SHAIR MUHAMMAD ROAD QUETTA
✉Email: sinahsquetta75@[Link]
✆PHONE: 0311-8013611
Mental Health Assessment Form
Patient Information
Patient Name: F/Name: Patient ID: Ethnicity:
Abdul Abdul Pashtoon
Patient Skills/Strength Khaliq
jabbar
Furniture Presenting problem
Maker
Presenting Mental Health Problem(s)
Schizophreni
History of presenting problem
a
Current symptoms His behavior is not good with family, lives alone,
Depressed.
Irritable, Depressed, Trouble in Goal for Treatment
Sleeping
Medical
The goal of this guideline is to improve the qualityHistory
of care and treatment outcomes for patients with
Current Medication schizophrenia
Medication Name Dose Frequency Indication Note: Started upon
Admission-2 days prior
Medical History
Family History No Medical history is
present.
Developmental History
Two brothers and
Parents.
Psychological History
Normal.
Personal History
Family History
He is a patient of
Schizophrenia.
Psychosocial History
Education No Problem in his
family.
Social Relationships
The patient is Uneducated according to his
family.
Living Situation
Social relationships are not
Developmental Historygood.
According to his family, he like to live
alone.
Chilhood/Adolecence
Developmental history in
Cultural Factors normal.
Not
Available. Substance Abuse History
Substance Age of First Use Date of last Use Note
Risk Screening
Select all that applies
□ Suicide/Self harm □ Neglect/Abuse □ Substance abuse
□ Cognitive Impairment □ Cultural isolation □ Homelessness
If any above is selected, please elaborate:
SINA INSTITUTE OF NURSING AND ALLIED HEALTH SCIENCES QUETTA
DOCTOR SHAIR MUHAMMAD ROAD QUETTA
✉Email: sinahsquetta75@[Link]
✆PHONE: 0311-8013611
Mental Status Exam
Client Name: Date:
OBSERVATIONS:
Appearance □ Neat □ Disheveled □ Inappropriate □ Bizarre □ Other
Speech □ Normal □ Tangential □ Pressured □ Impoverished □ Other
Eye Contact □ Normal □ Intense □ Avoidant □ Other
Motor Activity □ Normal □ Restless □ Tics □ Slowed □ Other
Effect □ Full □ Constricted □ Flat □ Labile □ Other
Comments:
MOOd
□ Euthymic Anxious Angry Depressed Euphoric Irritable Other
Comments:
COGNITION
Orientation Impairment □ None □ Place □ Object □ Person □ Time
Memory Impairment □ None □ Short-Term □ Long-Term □ Other
Attention □ Normal □ Distracted □ Other
Comments:
PERCEPTION
Hallucinatons None Auditory Visual Other
Others None Derealization Depersonalization
Comments:
THOUGHTS
Suicidality □ None □ Ideation □ Plan □ Intent □ Self-Harm
Homicidality □ None □ Aggressive □ Intent □ Plan
Delusions □ None □ Grandiose □ Paranoid □ Religious □ Other
Comments:
BEHAVIOR
□ Cooperative Guarded Hyperactive Agitated Paranoid
□ Stereotyped Aggressive Bizarre With Drawn Other
Comments:
INSIGHT □ Good □ Fair □ Poor Comments:
JUDGEMENT
□ Good □ Fair □ Poor Comments:
Physical Examination Result
Physically the patient is good no physical problem is found but psychologically he
needs treatment. Assessment Summary
Student Name: Session: Student Signature: Date:
Mehwish younis 2023- 24-09-2024
2025
Checked By:
