Client Name:

Age:
Gender:
Date:

✓ Tick where appropriate

Appearance and Behavior

Hygiene
Average Unclean Malodorous

Clothing/Grooming
Average, Appropriate Unkempt, Disheveled Atypical

Weight
Average Over-weight Under-weight

Physical Disabilities
Yes No

Other Features
Wounds Scars Tattoos
Jewelry Glasses Dental Braces

Eye Contact
Yes – Appropriate Sometimes No – Inappropriate Staring

Posture
Relaxed Slumped Rigid

Motor Activity
No unusual movements or Agitated, Fidgety, Restless, Decreased, Slowed.
psychomotor changes Pacing Psychomotor retardation
Unusual: Tics, Tremors,
mannerisms, gestures

Facial Expression
Joy, Reflective Fear, Anxious Sadness, Depression
Unusual, Atypical Anger, Hostile Absence of feelings

State of Consciousness
Alert Lethargic, Drowsy, Stupor Unresponsive, Even to pain

Attitude towards Interviewer

Cooperative, Open, Oppositional/ Provocative
Control, Domineering
Genuine, Attentive Hostile
Overly Compliant Suspicious, Guarded Resistant, Evasive

Other
Comments:

1 | Mental Status Exam Form

 Thought Process
Speech Rate
Appropriate, Controlled Rapid, Pressured, Slow Deliberate, Monotonous

Speech Volume
Appropriate, Audible Soft, Mute Loud

Speech Quantity
Appropriate, Concise Monosyllables, Minimal Detailed Elaborate

Speech Quality
Appropriate, Clear Stutters, Slurred, Mumble Impediments - ESL

Content of Thought
Linear and goal-directed Overvalued idea Trend of thought
Poverty of thought Thought withdrawal Thought insertion

Stream of Thoughts
Productivity
Average Overabundance Paucity
Spontaneous Needs prompting Mixed

Other
Comments:

Mood and Affect

Predominate Mood
Reflective Euphoric Elevated
Depressed, Dysthymic Angry Irritable, anxious

Affect
Broad and appropriate Restricted, limited range Blunted
Flat Inappropriate Labile, tearful, crying

Appropriateness of Affect to
Thought Content
Mostly congruent Sometimes congruent Not congruent

Other
Comments:

2 | Mental Status Exam Form

 Intellectual and Cognition Functioning
Executive Function
Abstract Thinking Concrete Thinking Description:

Information processing and

intelligence
Fund of Knowledge: Vocabulary: Self-expression:
High High High
Average Average Average
Low Low Low

Formal and Informal

Education
Completed Grades 1-12 BA, MA, PhD Informal

Attention
Average Distractable Hyper-vigilant

Concentration
Average Brief Deficient

Hallucination (no stimulus is

present).
Auditory: Do you hear
Visual: Do you see things
None voices? Do you follow the
others do not see?
voices?
Gustatory. Do you have
Olfactory: Smells that others
unexplained taste Others:
do not smell
sensations?

Illusions (misperceived
stimulus)
None Present Describe:

Derealization: Sense of
detachment from one’s
world/ environment.
None Present Describe:

Depersonalization: Sense of
detachment from one’s
sense of self. Often an
experience of anxiety.
None Present Describe:

Other
Comments:

Sensorium
Oriented: Time
Do you know the time?
Yes No

Oriented: Person
Do you know your name?
Yes No
3 | Mental Status Exam Form
Oriented: Place
Do you know where you are?
Yes No

Oriented: Circumstances
Do you know why you are
here?
Yes No

Other
Comments:

Memory
Immediate Memory:
Past few hours or minutes
Average Below Average No Data

Recent memory:
Recent past or day/month
Average Below Average No Data

Remote Memory:
Childhood or past HX
Average Below Average No Data

Other
Comments:

Judgment/Social Judgement
Does the individual notice
proper behavior? Moral
development.
Questions such as if
you found a wallet in
the supermarket, what would
you do?
Good Average Poor None No Data

Insight
The degree of awareness of
one’s strengths and/or
limitations
Good. Full awareness of Fair. Some awareness of Poor. Little or no awareness
one’s strengths and/or one’s strengths and/or of one’s strengths and/or
limitations limitations limitations

4 | Mental Status Exam Form

 Reliability of Report
Is the person a good Self-
historian?
Good Fair Poor

Other
Comments:

Examiner’s Signature:
Examiner’s Name:
License No.:
Date:

References:
Barlow, D., & Durand, M. (1995). Abnormal Psychology: An Integrative Approach 8th Edition (8th Edition, p.
79) [Review of Abnormal Psychology: An Integrative Approach 8th Edition].
The Mental Status Examination. (2022). Delmarlearning.com.
http://www.delmarlearning.com/companions/content/0766826899/res/mentstatexam.asp
Gaines, J. (2021, September 20). Mental Status Exams: 10 Best Templates, Questions & Examples.
PositivePsychology.com. https://positivepsychology.com/mental-status-examination/#templates
Newman, G. (2020, May). How to Assess Mental Status. MSD Manual Professional Edition; MSD Manuals.
https://www.msdmanuals.com/professional/neurologic-disorders/neurologic-examination/how-to-assess-
mental-status

5 | Mental Status Exam Form