MENTAL STATUS INVENTORY (MSI)

BELDEROL, J.V., CAETE, J., COMICHO, B., MORAL, S., MORANDANTE, R.

2017

The MSI is designed to organize data about a clients psychological functioning upon the instance of referral. Combined with biographical and historical data, the MSI can guide the clinician in
formulating a valid diagnosis requisite of creating an integrative treatment plan.

PERSONAL DATA
NAME: AGE SEX ETHNICITY

ADDRESS: CONTACT NUMBER

REFERRED BY: DATE OF ADMINISTRATION

TIME STARTED TIME ENDED

EDUCATIONAL BACKGROUND _______________________________________________________________________________________________________

______________________________________________________________________________________________________

EMPLOYMENT _______________________________________________________________________________________________________
_______________________________________________________________________________________________________

ADMINISTERED BY/DATE SUPERVISED BY/DATE: The data recorded here are based on clinical observation and assessment of the client during initial
referral. The purpose of this assessment is to have a basis for further action in terms of the
psychological welfare of the client. Any questions or clarifications on this report may be directed to
_________ with office address at ________________ telephone number/mobile number or
_____________________________________ _____________________________________ email____________.
License No. License No.
 PART I. Encircle your rating of the client for each descriptor. Write other pertinent details and observations of the client in the remarks column.

I. GENERAL APPEARANCE

LOOKS VERY YOUNG LOOKS VERY OLD REMARKS (Mga Dugang na Impormasyon)
IN RELATION TO AGE IN RELATION TO AGE
APPEARANCE IN RELATION Bata Kaayo Tan-awon Tiguwang Kaayo
1a TO AGE Sa iyang edad Tan awon sa iyang edad

Itsura kumpara sa Edad 1 2 3 4 5

UNDERWEIGHT OVERWEIGHT REMARKS (Mga Dugang na Impormasyon)
Gamay kaayo og Dako kaayo og
Timbang Timbang
1b BODY WEIGHT 1 2 3 4 5
Timbang sa Lawas
METICULOUSLY DIRTY & REMARKS (Mga Dugang na Impormasyon)
CLEAN UNBATHED
1c HYGIENE AND GROOMING Grabe ka limpyado Hugaw kaayo og
Kalimpyo sa Panglawas walay ligo

1 2 3 4 5
REMARKS (Mga Dugang na Impormasyon)
NO CONTACT FIXED GLARING
1d Dili Gatan-aw sa Straight Ang Gapanglisik ang
EYE CONTACT kaistorya Tinan-awan Ang Mata
Tinan-awan 1 2 3 4 5
Encircle at least two. REMARKS (Mga Dugang na Impormasyon)

HAPPY SAD AFRAID-CONFIDENT

1e FACIAL EXPRESSION WORRIED-RELAXED RESPONSIVE-PREOCCUPIED
BORED-INTERESTED SMILING-SCOWLING

ADMINISTERED BY/DATE SUPERVISED BY/DATE: The data recorded here are based on clinical observation and assessment of the client during initial
referral. The purpose of this assessment is to have a basis for further action in terms of the
psychological welfare of the client. Any questions or clarifications on this report may be directed to
_________ with office address at ________________ telephone number/mobile number or
_____________________________________ _____________________________________ email____________.
License No. License No.
II. PSYCHOMOTOR BEHAVIOR

INAPPROPRIATE APPROPRIATE REMARKS (Mga Dugang na Impormasyon)

2a POSTURE & GAIT 1 2 3 4 5

PSYCHOMOTOR HYPERACTIVE/ REMARKS (Mga Dugang na Impormasyon)
RETARDATION RESTLESS

2b ACTIVITY 1 2 3 4 5
UNCOOPERATIVE COOPERATIVE REMARKS (Mga Dugang na Impormasyon)
2c CLIENT INTERACTION
1 2 3 4 5

III. MOOD , AFFECT AND EMOTIONAL REACTIVITY

INCONGRUENT CONGRUENT REMARKS (Mga Dugang na Impormasyon)

3a APPROPRIATENESS OF
AFFECT 1 2 3 4 5
RESTRICTED BROAD REMARKS (Mga Dugang na Impormasyon)
3b RANGE OF AFFECT
1 2 3 4 5
LABILE STABLE REMARKS (Mga Dugang na Impormasyon)
3c STABILITY OF AFFECT
1 2 3 4 5

ADMINISTERED BY/DATE
_____________________________________
License No.
SUPERVISED BY/DATE: The data recorded here are based on clinical observation and assessment of the client during initial
referral. The purpose of this assessment is to have a basis for further action in terms of the
psychological welfare of the client. Any questions or clarifications on this report may be directed to
_________ with office address at ________________ telephone number/mobile number or
_____________________________________ email____________.
License No.
 FLAT EUPHORIC REMARKS (Mga Dugang na Impormasyon)

3d INTENSITY OF AFFECT 1 2 3 4 5
PSYCHOMOTOR HYPERACTIVE/ REMARKS (Mga Dugang na Impormasyon)
RETARDATION RESTLESS

3e ANXIETY LEVEL
1 2 3 4 5

IV. SPEECH AND LANGUAGE

POVERTY OF WORDS VERBOSE REMARKS (Mga Dugang na Impormasyon)

4a QUANTITY
1 2 3 4 5
INAUDIBLE LOUD REMARKS (Mga Dugang na Impormasyon)
4b INTENSITY OF VOLUME
1 2 3 4 5
SLOW FAST REMARKS (Mga Dugang na Impormasyon)
4c RATE
1 2 3 4 5

ADMINISTERED BY/DATE
_____________________________________
License No.
SUPERVISED BY/DATE: The data recorded here are based on clinical observation and assessment of the client during initial
referral. The purpose of this assessment is to have a basis for further action in terms of the
psychological welfare of the client. Any questions or clarifications on this report may be directed to
_________ with office address at ________________ telephone number/mobile number or
_____________________________________ email____________.
License No.
PART II. Below are statements of observations of the client. Please encircle your level of agreement with each statement. Use the rating scale below:

1 Strong Disagree (SD) 2- Disagree (D) 3-Undecided (U) 4- Agree (A) 5-Strongly Agree (SA)

THOUGHT FORM The client SD D U A SA REMARKS

A1 has a sudden interruption of thought or speech. 1 2 3 4 5
A2 refuses to speak. 1 2 3 4 5
A3 repeats meaninglessly the clinicians words. 1 2 3 4 5
A4 forms new words to express ideas. 1 2 3 4 5
A5 skips from one topic to another in a fragmented, often rapid fashion 1 2 3 4 5
A6 ...involuntarily repeats the answer to a previous question in response to a 1 2 3 4 5
new question
A7 uses a mixture of words and phrases lacking comprehensive meaning or 1 2 3 4 5
coherence
A8 talks quickly and in such a way that interruption is difficult. 1 2 3 4 5
A9 misses the point of the question. 1 2 3 4 5
A10 is being incidental and irrelevant in stating details. 1 2 3 4 5

THOUGHT CONTENT The client SD D U A SA REMARKS

B1 ...has unwanted, recurring thoughts. 1 2 3 4 5
B2 ... has unrealistic exaggeration of his/her own importance. 1 2 3 4 5
B3 believes that he/she is being singled out for attack or harassment. 1 2 3 4 5

B4 believes that he/she is able to control others through ones thoughts. 1 2 3 4 5

B5 believes that others are able to control the client. 1 2 3 4 5

ADMINISTERED BY/DATE SUPERVISED BY/DATE: The data recorded here are based on clinical observation and assessment of the client during initial
referral. The purpose of this assessment is to have a basis for further action in terms of the
psychological welfare of the client. Any questions or clarifications on this report may be directed to
_________ with office address at ________________ telephone number/mobile number or
_____________________________________ _____________________________________ email____________.
License No. License No.
B6 has a total misinterpretation of physical symptoms. 1 2 3 4 5
B7 believes that he/she doesnt exist, and that others and the world are 1 2 3 4 5
non-existent.
B8 has false sensory perceptions without external stimuli 1 2 3 4 5
B9 interprets casual incidents as being directed toward the self. 1 2 3 4 5

SUICIDE AND HOMICIDAL POTENTIAL The client SD D U A SA REMARKS

C1 ...feels that his/her life is not worth living. 1 2 3 4 5
C2 ... has occasionally thought of killing himself/herself. 1 2 3 4 5
C3 has envisioned how things would be after he/she dies. 1 2 3 4 5
D1 has thought about hurting others who have wronged him/her. 1 2 3 4 5
D2 has thought about getting even with people who have wronged 1 2 3 4 5
him/her.
D3 has had the desire to hurt others. 1 2 3 4 5

PART III. This section evaluates the General Sensorium and Intellectual Status of the client. Please circle the appropriate box of your rating for each descriptor. Use the scale below:

1-Poor 2- Fair 3-Good

General Sensorium and Intellectual Status P F G REMARS

E1 Attention 1 2 3
E2 Concentration 1 2 3
E3 Orientation of Time 1 2 3
E4 Orientation of Place 1 2 3

ADMINISTERED BY/DATE SUPERVISED BY/DATE: The data recorded here are based on clinical observation and assessment of the client during initial
referral. The purpose of this assessment is to have a basis for further action in terms of the
psychological welfare of the client. Any questions or clarifications on this report may be directed to
_________ with office address at ________________ telephone number/mobile number or
_____________________________________ _____________________________________ email____________.
License No. License No.
E5 Orientation of Person 1 2 3
E6 Orientation of Situation 1 2 3
E7 Immediate Memory 1 2 3
E8 Remote Memory 1 2 3
E9 Recent Memory 1 2 3
E10 Progressive Subtractions of 7s from 100s 1 2 3
E11 General Information 1 2 3
E12 Vocabulary 1 2 3
E13 Abstractions 1 2 3
E14 Judgment and Reasoning 1 2 3
E15 Insight into Illness 1 2 3

GENERAL ASSESSMENT: ________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________

ADMINISTERED BY/DATE SUPERVISED BY/DATE: The data recorded here are based on clinical observation and assessment of the client during initial
referral. The purpose of this assessment is to have a basis for further action in terms of the
psychological welfare of the client. Any questions or clarifications on this report may be directed to
_________ with office address at ________________ telephone number/mobile number or
_____________________________________ _____________________________________ email____________.
License No. License No.
LEVEL OF FUNCTIONALITY
A. SOCIAL INTERACTION
Functioning Mildly Impaired Moderately Impaired Severely Impaired

B. OCCUPATION
Functioning Mildly Impaired Moderately Impaired Severely Impaired

C. SELF-CARE
Functioning Mildly Impaired Moderately Impaired Severely Impaired

D. COGNITIVE FUNCTIONING
Functioning Mildly Impaired Moderately Impaired Severely Impaired

LEVEL OF MONITORING
CONSTANT MONITORING
The most restrictive a staff person must be sitting with the patient constantly (e.g. patients who are extremely suicidal or high-risk to harm
themselves or others).
LEVEL 1
Patient must be observed every 15 minutes. Patient must be in hospital pajamas and can wander on his own, but cannot leave the unit.
LEVEL 2
Patient must be observed every 30 minutes Patient can wear his own clothes and leave the unit with a responsible adult.
LEVEL 3
The least restrictive. Patient can wear his own clothes, leave the unit, and account for his whereabouts, but the nurse needs to know where the patient
is every hour for those admitted to an acute care unit, or per the residents care plan for those in a tertiary mental health facility.

ADMINISTERED BY/DATE SUPERVISED BY/DATE: The data recorded here are based on clinical observation and assessment of the client during initial
referral. The purpose of this assessment is to have a basis for further action in terms of the
psychological welfare of the client. Any questions or clarifications on this report may be directed to
_________ with office address at ________________ telephone number/mobile number or
_____________________________________ _____________________________________ email____________.
License No. License No.
ENDORSEMENT
FOR ADMISSION OUT-PATIENT FOR REFERRAL

References:

New Day Recovery Center Mental Status Examination Form

Lakeman, R. (1995). Teaching resource mental status examination. Retrieved from www.testandcalc.com. [PDF].

ADMINISTERED BY/DATE SUPERVISED BY/DATE: The data recorded here are based on clinical observation and assessment of the client during initial
referral. The purpose of this assessment is to have a basis for further action in terms of the
psychological welfare of the client. Any questions or clarifications on this report may be directed to
_________ with office address at ________________ telephone number/mobile number or
_____________________________________ _____________________________________ email____________.
License No. License No.
 MENTAL STATUS INVENTORY (MSI)
BELDEROL, J.V., CAETE, J., COMICHO, B., MORAL, S., MORANDANTE, R.
2017

SUGGESTED ITEMS FOR REMARKS COLUMN

PART I
ITEM DESCRIPTOR ADDITIONAL DATA FOR REMARKS COLUMN
NO.
1a Appearance in Relation to Age Cause of appearance-related aging (stress, type of
clothes worn, accessories, etc)
1b Body Weight Body built
GENERAL APPEARANCE

Height
Muscle tone
1c Hygiene and Grooming Clothing Appropriate to age, season, setting and
occasion? Clean,neat, tidy, meticulous, worn,
properly worn? Are the colours worn: bright, dull,
drab?
Cosmetics Worn / applied properly, carefully or
carelessly?
Odor
1d Eye Contact Fleeting? Darting?
1e Facial Expression Suspicious? Dazed? Tense? Incongruent with body
language and/or speech?
2a Posture and Gait Gait : Brisk, slow, hesitant, propulsive, shuffling,
dancing, normal, ataxic,, uncoordinated.
Handshake: Firm weak, warm, cool, resistant,
heavy, refused, prolonged, seductive.
Abnormal movements: Grimaces, tics, twitches,
Psychomotor behavior

foot tapping, hand wringing, ritualistic behaviour,

mannerisms, posturing, nail biting, chewing
movements, echopraxia.
Posture: Stooped, relaxed, stiff, shaky, slouched,
bizarre mannerisms, posturing, crouching, erect.
2b Activity Co-ordination of movements:Awkward, clumsy,
agile, falling easily.
Mannerisms
2c Client interaction Cooperative, hostile, open, secretive, evasive,
suspicious, apathetic, easily distracted, focused,
defensive.
3a Appropriateness of Affect Consistency of mood
Appropriateness of situation
Mood, affect and Emotional

3b Range of Affect Lively, flat, normal, blunted, superficial, constricted

3c Stability of Affect Quality: Sad, angry, hostile, indifferent, euthymic,

dysphoric, detached, elated, euphoric, anxious,
animated, irritable.
3d Intensity of Affect Blunted affect?
Reactivity

3e Anxiety Level Mild , Moderate, severe, triggers for anxiety?

4a Quantity Responds only to questions; offers information;

sp

ch
ee

scant; mute; verbose, repetitive.

ADMINISTERED BY/DATE SUPERVISED BY/DATE: The data recorde

referral. The purp
psychological we
_________ with o
_____________________________________ _____________________________________ email__________
License No. License No.
 4b Intensity of volume Lively, dull, monotonous, normal, intense,
pressured,explosive.
4c Rate Hesitant, expansive, rambling, halting, stuttering,
lilting, jerky, long pauses, forgetful.

PART II THOUGHT FORM AND THOUGHT CONTENT

A1 has a sudden interruption of thought or speech. BLOCKING

A2 refuses to speak. MUTISM
A3 repeats meaninglessly the clinicians words. ECHOLALIA
A4 forms new words to express ideas. NEOLOGISMS
A5 skips from one topic to another in a fragmented, often FLIGHT OF IDEAS
rapid fashion
A6 ...involuntarily repeats the answer to a previous PERSEVERATION
question in response to a new question
A7 uses a mixture of words and phrases lacking WORD SALAD
comprehensive meaning or coherence
A8 talks quickly and in such a way that interruption is PRESSURE OF SPEECH
difficult.
A9 misses the point of the question. TANGENTIAL SPEECH
A10 is being incidental and irrelevant in stating details. CIRCUMSTANTIALITY

B1 ...has unwanted, recurring thoughts. Obsessions

B2 ... has unrealistic exaggeration of his/her own Grandiose delusion
importance.
B3 believes that he/she is being singled out for attack Persecutory delusion
or harassment.
B4 believes that he/she is able to control others Influential active delusion
through ones thoughts.
B5 believes that others are able to control the client. Passive influence delusion
B6 has a total misinterpretation of physical symptoms. Somatic delusion
B7 believes that he/she doesnt exist, and that others Nihilistic delusion
and the world are non-existent.
B8 has false sensory perceptions without external Hallucination (auditory, visual, olfactory,
stimuli gustatory, tactile, kinesthetic)
B9 interprets casual incidents as being directed Ideas of reference
toward the self.

C1 ...feels that his/her life is not worth living. Suicidal potential

C2 ... has occasionally thought of killing himself/herself.
C3 has envisioned how things would be after he/she
dies.
D1 has thought about hurting others who have wronged Homicidal potential
him/her.
D2 has thought about getting even with people who
have wronged him/her.
D3 has had the desire to hurt others.

ADMINISTERED BY/DATE SUPERVISED BY/DATE: The data recorde

referral. The purp
psychological we
_________ with o
_____________________________________ _____________________________________ email__________
License No. License No.
PART 3
General Sensorium and Intellectual POSSIBLE ACTIVITIES/ QUESTIONS
Status
E1 Attention Digit Span (forward and reverse) - Suggested patient instructions:
I will recite a series of numbers to you, and then I will ask you to repeat
them to me, first forwards
and then backwards. [Begin with 3 numbers not consecutive numbers,
and advance to 7-8
numbered sequence.]

E2 Concentration . Spelling Backwards - Suggested patient instructions:

Spell the word world. Now spell the word world backwards.
E3 Orientation of Time What is your full name?
Where are we at (floor, building, city, county, and state)?
E4 Orientation of Place
What is the full date today (date, month, year, day of the week, and
E5 Orientation of Person season of the year)?
How would you describe the situation we are in?
E6 Orientation of Situation
E7 Immediate Memory I am going to ask you to remember three words (color, object, animal e.g.,
blue, table, and horse)
and I will ask you to repeat them to me in 5 minutes. Please repeat them
now after me: blue, table,
and horse. 5 minutes elapse What were those three words I asked you
to remember? [Monitor
accuracy of response, awareness of whether responses are correct,
tendency to confabulate or
substitute other words, ability to correct themselves with category clue and
multiple choice].

E8 Remote Memory What were the dates of your graduation from high school, college,
graduate school?
E9 Recent Memory What is my name?
What medications did you take today?
What time was your appointment with me for today?
E10 Calculations Progressive Subtractions of 7s from 100s
E11 General Information Name the current president, vice president, governor, and mayor
E12 Vocabulary Grade school level, high school level, fluent, consistent with education.
E13 Abstractions 1.Similarities How are the following items similar?
an apple and an orange (round ~concrete, fruit ~abstract)
a chair and a table (made of wood ~concrete, furniture ~abstract)
a watch and a ruler (measurement instruments ~abstract)
2. Proverbs How would you describe the meaning of the following
sayings?
People living in glass houses should not throw stones.
A bird in the hand is worth two in the bush.
You shouldnt cry over spilt milk.
Two heads are better than one.
E14 Judgment and Reasoning Impulsive behaviour with examples. Able to come to
appropriate conclusions; unrealistic decisions
E15 Insight into Illness Complete denial; recognizes there is a problem but projects
blame; both intellectual and emotional awareness. Perception
of illness.

ADMINISTERED BY/DATE SUPERVISED BY/DATE: The data recorde

referral. The purp
psychological we
_________ with o
_____________________________________ _____________________________________ email__________
License No. License No.
ADMINISTERED BY/DATE SUPERVISED BY/DATE: The data recorde
referral. The purp
psychological we
_________ with o
_____________________________________ _____________________________________ email__________
License No. License No.