Clothing

1. The patients clothing was neat and clean./neat and

fair/neat and fresh
2. The patients clothing was appropriate.
3. He was neatly dressed.
4. The patients clothing was normal.
5. He was dressed normal cloths.
6. The patients clothing was adequate.
7. He is casually dressed.
8. He was clothed in a good manner.
9. The patients clothing was inappropriate.
10. The patients clothing was dirty.
11. He was dressed dirty cloths.
12. The patients clothing was inadequate.
13. He was dressed in a careless way/ manner
14. He was dressed in bizarre clothing.
Grooming and Hygiene

1. He was well groomed and hygienic.

2. The patient appeared hygienic and cooperative.
3. Level of grooming was normal.
4. He maintains personal hygiene.
5. His hygiene was adequate.
Age

1. He looked appropriate as per his age.

2. He presented himself looking his stated age

3. He appeared in his stated age

4. Mr. Test is 34 years old who appears as to be stated age.
5. Patient appears much older than his or her chronological age
6. Patient appears older than his chronological age
7. Patient appears younger than his chronological age.
8. She appeared to be of average size and weight for her gender and
chronological age.

D. Body Built

1. His body built was average.

2.

His body built was light.

3.

His body built was heavy.

E. Physique

1. His physique was slender with adequate development and

in proportion.
2. His physique was adequate/ normal/ average
3. His physique was average in size with adequate development
and in proportion.

F. Physical Appearance

1. His appearance was normal, short height, and appropriate

weight
2. His appearance was normal, tall height, and slightly overweight.
3. His appearance was normal, tall height, and underweight.
4. His appearance was normal, tall height, and appropriate weight.
5. She appeared to be of average size and weight for her gender and
chronological age.

G. Physical Health

1. Overall he appeared to be in good physical health.

2. Overall he appeared to be unhealthy.
H. Signs of Anxiety

1. There were no visible signs of anxiety in the patient

I. Level of Comfort

2. He appeared to be comfortable.
3. He appeared to be initially uncomfortable during the interview.

II. OVERT BEHAVIOUR AND PSYCHOMOTOR ACTIVITY (Observed)

Observations were made in relation to the patients overt

behaviour and psychomotor activity.
A. Attitude Toward Examiner/Accessibility
1. He was cooperative when Mental Status Exam (MSE) was
administered onto him.
2. He was cooperative, attentive and talkative.

3. His attitude towards examiner was friendly, cooperative,

attentive and interested.
4. His attitude towards examiner was friendly, cooperative,
dependent, interested, argumentative, manipulative and frank.
5. His attitude towards examiner was friendly, cooperative,
confused, interested, irritable and frank.
6. He was conscious, cooperative
B. Eye Contact
1.

Eye contact of patient was adequate

C. Facial Expressions

1. His facial expressions were responsive and smiling during

the interview.
2. His facial expressions were responsive, sad and preoccupied
during the interview.
3. His facial expressions were responsive and sad during the
interview.
4. He looks sad
C. Gait

His gait was appropriate

His gait was slow
D. Handshake

His handshake was weak.

E. Posture

His posture was relaxed

His posture was stooped

G. Abnormal Movements

No abnormal movements were noted

Nothing unusual was observed in relation to appearance of the
patient.
H. Rate of Movements

Rate of movements was moderate.

Rate of movements was slow.
i.

Coordination of Movements

His coordination of movements was well-coordinated.

J. Comprehension

Comprehension of the patient was fully functional.

K. Rapport
1.

A good rapport was established.

2.

Rapport could be established easily

3.

The rapport establishment was easy.

4. A good rapport was established and patient seemed to provide

some inaccurate and dishonest details about identifying data,
chief complaint, the nature of his present and past illnesses
and life history.
5. Many discrepancies were elicited when the patients case file
was reviewed.
6. A working and empathetic relationship could be established
with the patient.