Brief Mental Status Exam (MSE) Form

1. Appearance 2. Attitude 3. Behavior 4. Speech 5. Affect

casual dress, normal grooming and hygiene other (describe): calm and cooperative other (describe): no unusual movements or psychomotor changes other (describe): normal rate/tone/volume w/out pressure other (describe): reactive and mood congruent labile tearful blunted other (describe): euthymic irritable elevated other (describe): goal-directed and logical other (describe): Suicidal ideation: None passive If active: yes plan intent means delusions phobias other (describe): normal range depressed constricted flat

6. Mood

anxious depressed

7. Thought Processes 8. Thought Content

disorganized

active no

Homicidal ideation: None passive

active

If active: yes no plan intent means obsessions/ compulsions

9. Perception 10. Orientation 11. Memory/ Concentration 12. Insight/Judgement

no hallucinations or delusions during interview other (describe): Oriented: time place other (describe): short term intact other (describe): good fair poor person self

long term intact distractable/ inattentive

_______________________________________________________

___________________

Practitioner Signature
________________________________________________________

Date
___________________

Patient Name
http://www.apshealthcare.com/provider/documents/brief_mental_status.pdf

ID#