MENTAL HEALTH CHECKLIST KLINIK KESIHATAN AYER MOLEK

(√) IF YES, (X) IF NO, (n) IF NORMAL

ITEM DATE

Assessment of symptoms
Sleep disturbances
Appetite
Loss of interest
Loss of weight
Suicidal
Feeling fearful
Palpitation
Able to do daily activity
Memory impairment
Substance abuse
Assessment of associated symptoms
Constipation/diarrhoea
Reduce libido/impotence
Headache
Assessment of compliance
Assessment of side effects
Physical examinations
Weight
BMI
BP/PR
MSE
Appearance
Mood
Affect
Behaviours
Orientation
Speech
Delusion
Hallucinations
insight/judgement
Relevant investigations
Yearly cardiovascular risk assessment
Sign and symptoms of relapse?
PLAN

MO NAME & DESIGNATION