MENTAL STATUS / BEHAVIORAL CHECKLIST

Client: Observer: Date:

Present
No Somewhat Yes
1. physically unkempt, unclean
2. clothing disheveled, dirty clothing
APPEARANCE 3. atypical, unusual, bizarre unusual
4. physical characteristics

Comments:

Present
No Somewhat Yes
5. slumped
6. rigid, tense
POSTURE 7. unusual, inappropriate

8. anxiety, fear, apprehension

9. depression, sadness
FACIAL 10. anger, hostility
B EXPRESSION 11. unchanging or fixed expression
E SUGGESTS 12. bizarreness, inappropriateness

H 13. accelerated, increased speed, hyper

A GENERAL BODY 14.
15.
decreased, slowed
peculiar, inappropriate
V MOVEMENTS 16. restlessness, fidgety
I 17. increased, loud
O SPEECH 18. decreased, slowed
19. unusual, slurring stammering
R
CLIENTS ATTITUDE 20. domineering
21. submissive, overly compliant
TOWARD TESTING / 22. provocative
EXAMINER 23. suspicious
24. uncooperative

Comments:

Present
No Somewhat Yes
25. emotion inappropriate for situation
26. emotional swings
FEELING 27. flat, unvarying mood
28. euphoric, elated(happy) mood
AFFECT 29. angry, hostile mood
30. fearful, anxious, apprehensive
MOOD 31. depressed, sad

Comments:

MENTAL STATUS / BEHAVIORAL CHECKLIST, CONTINUED

Present
 No Somewhat Yes
32. illusions (erroneous perceptions)
33. auditory hallucinations
PERCEPTION 34. visual hallucinations
35. other type of hallucination

Comments:

Present
No Somewhat Yes
36. impaired level of consciousness
37. impaired attention span
38. impaired abstract thinking
39. impaired calculation ability
40. impaired intelligence

INTELLECTUAL 41. person

FUNCTIONING 42. place
43. time

44. difficulty acknowledging presence of

ORIENTATION TO psychological problems
45. blames others or circumstances for most
problems
T 46. impaired ability to manage daily living
INSIGHT
H activities
47. impaired ability to make reasonable life
I decisions
N JUDGMENT 48. impaired immediate memory
49. impaired recent memory
K 50. impaired remote memory
I
MEMORY 51. obsessions
N 52. compulsions
53. phobias
G 54. derealization / depersonalization
55. suicidal thoughts
56. homicidal thoughts
57. delusions (false beliefs)
THOUGHT 58. ideas of reference (“actions or talk of others
CONTENT somehow relate to me”)
59. ideas of influence (one has more impact or
influence than is true)

60. loose associations

STREAM OF THOUGHT 61. decreased / slow thought flow
(AS MANIFESTED BY 62. increased thought flow
SPEECH)
Comments: