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Mental Health Assessment Form

Patient name Physician Psychiatrist Date of Assessment Problem 1. 2. 3. Mental Health History/Treatment Risk Diagnosis Date of Birth Gender

Medications

Allergies

Family History of Mental Illness

Medical Conditions

Social History

Abuse history – substance/sexual/physical

Alcohol use:

Tobacco:

BMI:

Personal History (eg childhood, education, relationship history, coping with previous stressors)

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Relevant Physical and Mental Examination Investigations Mental Status Examination Appearance and General Behaviour Thinking (Content / Rate / Disturbances) Perception (Hallucinations etc) Cognition (Level of Consciousness / Delirium / Intelligence) Attention / Concentration Memory (Short & Long term) Insight Orientation (Time / Place / Person) Risk Assessment Suicidal ideation Current plan Key Family/ Support Contact Mood (Depressed / Labile) Affect (Flat / Blunted) Sleep (Initial Insomnia / Early Morning Wakening) Appetite (Disturbed Eating Patterns) Motivation / Energy Judgement (Ability to make rational decisions) Anxiety Symptoms (Physical & Emotional) Speech (Volume / Rate / Content) Suicidal intent Risk to Others FORMULATION – Main problem / diagnosis (risk / protective factors) ICD – 10 Provisional Diagnosis F1 Alcohol & Drug Use disorder  F2 Psychotic Disorder  F3 Depression  F4 Anxiety Disorder  F5 Unexplained Somatic Disorder  Other / Unknown: Patient Education Notes Yes  No  Date for Mental Health Plan Name of nurse completing assessment Signed Date 2 .