A.

Identification
 Name
 Age
 Marital Status
 Sex
 Occupation
 Language
 Race
 Nationality
 Source & reliability
 Previous admissions
 With whom the patient lives
B. Chief complaint
C. History of present illness

D. Past psychiatric and medical history

E. Family history

F. Personal history
1. Early childhood

2. Middle childhood

3. Later childhood

4. Adulthood
I. Mental Status
A. Appearance
1. Personal identification

2. Behavior and psychomotor activity

3. General description

B. Speech

C. Mood and affect

1. Mood

2. Affect

D. Thinking and perception

1. Form of thinking

2. Content of thinking

3. Thought disturbances

4. Perceptual disturbances

5. Dreams and fantasies

E. Sensorium
1. Alertness

2. Orientation

3. Concentration and calculation

4. Memory

5. Fund of knowledge

6. Abstract thinking

F. Insight

G. Judgment