MENTAL STATUS EXAMINATION

PERSONAL DATA:
Name: Date:
Address: Time
Age: Occupation:
Nationality: Religion:
Date of Admission: Reason of Admission:
Medical Diagnosis:
Attending Physician:

I. GENERAL DESCRIPTION

Behavior & Psychomotor Activity

A. General Mobility: Normal

a. Posture & Gait

Justification: assistance.

b. Action & Gesture

( ) Normal ( ) Inappropriate

Justification:
c. Facial Expression

( ) smiling ( ) Worried ( ) Sad

( ) Ecstatic ( ) Tense ( ) Tearful

( ) Happy ( ) Frightening ( ) Distant

( ) Angry ( ) Suspicious

Justification:

B. Behavior

( ) Depressed ( ) Impulsive ( ) Angry

( ) Embarrassed ( ) Negativistic ( ) Seductive

( ) Indifferent ( ) Withdrawn ( ) Manic

Justification:

C. NURSE- PATIENT INTERACTION

a. Attention

( ) Cooperative ( ) Uncooperative

( ) Intitially ( ) Lately ( ) All through out

Justification:

b. Quality

( ) Warm ( ) Distant ( ) Dependent

( )Hostile ( ) Suspicious ( ) Talkative

Justification:.

II. EMOTIONAL STATE & REACTION MOOD

a. Mood

( ) Depressed ( )Angry ( ) Frightened

( )Anxious ( )Suspecious ( ) Talkative

Justification:

b. Affect

( ) Appropriate ( ) Inappropriate

Justification:

c. Quality

( ) Flat ( ) Blunted

III. NEUROVEGETATIVE FUNCTION

A. Sleep

( ) Normal ( ) Hypersomnia

( ) Early Insomnia ( ) Late Insomnia

 ( ) Mixed Insomnia

Justification:

B. Appetite

( ) Normal ( ) Increased ( ) Decreased

Justification:

C. Weight

( ) Increased ( ) Decreased ( ) Not Changes

Justification:

D. Diurnal Variation

E. Libido

IV. Speech & Stream of Talk

A. Character

( )Spontaneous ( )Deliberate ( ) Loud ( ) Talkative

( )Whispered ( ) Mumbled ( )Hesitant ( ) Pressured

Justification:
B. Accessibility

( )Good ( )Defensive ( ) Fair ( ) Mute

Justification:

C. Organization of Thoughts

( )Relevant ( )Irrelevant ( ) Circumstantial

( )Tangential

Justification:

V. Perception

( ) Present ( ) Absent

Justification:

VI. Thought

A. Delusion

( ) Present ( ) Absent

Justification:

B. Suicidal Potential
 ( ) Present ( ) Absent

Justification:

C. Homicidal Potential

( ) Present ( ) Absent

Justification:

VII. Sensorium & Cognition

A. Orientation

( ) Time

Justification: ( impaired/ Unimpaired)

( ) Place

Justification: ( impaired/ Unimpaired)

( ) Person
Justification: ( impaired/ Unimpaired)

B. Memory

( ) Remote

Justification: ( impaired/ Unimpaired)

( ) Recent

Justification: ( impaired/ Unimpaired)

( ) Recent Past

Justification: ( impaired/ Unimpaired)

( ) Immediate

Justification: ( impaired/ Unimpaired)

C. Attention Span
 ( ) Good ( ) Fair ( ) Poor

Justification:

D. Calculation:

E. Spelling

A. Abstract Thinking Ability

I. Judgment

( ) Impaired ( ) Unimpaired

Justification:

Insight

( ) Impaired ( ) Unimpaired

Justification:
II. Summary of Mental Status

A. Disturbances in:

( ) General Description

( ) Emotional State & Reaction Mood

( ) Neurovegetative Function

( ) Speech & Steam of Talk

( ) Perception

( ) Thought

( ) Sensorium & Cognition

( ) Judgement & Insights

Diagnostic Category

( ) Pschotic ( ) Non- Psychotic

Justification:

B. DSM IV Diagnosis

Axis I

Axis II

Axis III

Axis IV

Axis V