Student: ________________________________________________ Clinical Group/Year Level: ____________________

Date/Time of Interview: ____________________________________ Interviewee: _______________________________

I. PATIENT’S DEMOGRAPHIC PROFILE

Patient Name: _____________________________________________________________________ Age/Sex:_____
Date of Birth: ___________________ Place of Birth: ____________________________________________________
Permanent Address: _____________________________________________________________________________
Nationality: _________________________ Religion: _____________ Educational Attainment: ___________________

Admission Date and Time: __________________________ Re-admission: __________________________________

Attending Physcician: ____________________________________________________________________________

Chief Complaint: _______________________________________________________________________________

Admitting Diagnosis: ____________________________________________________________________________
Final Diagnosis: ________________________________________________________________________________

Vital Signs upon Admission:

Temp.-_____°C PR-______ bpm RR-_____ cpm BP- _____/_____ mmHg
O2 Sat- _____ % Wt.-_____ kg. Ht.-_____ ft.

II. MENTAL STATUS EXAMINATION

A. GENERAL APPEARANCE (Observed)

1. Observe how pt dresses, hygiene, grooming.
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2. Observe if appropriately dressed for age and weather.
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3. Does pt appear to be their stated age?
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4. Observe pt’s posture.
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B. BEHAVIOR (Observed)
1. Observe if there are any types of mannerisms, gestures. (tics, automatisms, psychomotor
retardation)
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2. Observe facial expression and eye contact.
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3. Observe ability to follow commands/requests.
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C. ATTITUDE (Observed)
1. Observe if cooperative, hostile, open, secretive, evasive, suspicious, apathetic, easily distracted,
focused, defensive.
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D. LEVEL OF CONSCIOUSNESS (Observed)
1. Vigilant, alert, drowsy, lethargic, stuporous, asleep, comatose, confused, fluctuating.
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E. ORIENTATION (Inquired) Oriented x3 (time, place person) Oriented x2 (place, person) Oriented x1
(person only)
1. “Ano imo ngaran ma’am/sir?”
2. “Hain man kita yana nga (floor, building, siyudad)?”
3. “Maaram ka han petsa yana nga adlaw? (adlaw/petsa, bulan, tuig, adlaw han semana)?”
4. “Kun ikaw masaysay haakon hit natatabo yana ngan kun nag aano kita ano man imo
mayayakan?”
F. SPEECH AND LANGUAGE (Observed)
● Quantity - Possible descriptors:
- Talkative, spontaneous, expansive, paucity, poverty.
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● Rate - Possible descriptors:
- Fast, slow, normal, pressured.
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● Volume (Tone) - Possible descriptors:
- Loud, soft, monotone, weak, strong.
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● Fluency and Rhythm - Possible descriptors:
- Slurred, clear, with appropriately placed inflections, hesitant, with good articulation,
aphasic.
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G. MOOD (Inquired)
● “Kumusta ka man yana?”
● “Ano man tim inaabat yana?”
● “Inabat ka ba hin kamasulubuon ha mga naglabay na mga adlaw?
● “Inabat ka ba hin kahyper o damo it enerhiya nga diri mo makontrol ha mga naglabay na mga
adlaw?
● “Inabat ka ba hin kamaaringiton o madali mag isog ha mga naglabay na mga adlaw?”

H. AFFECT (Observed)
● Appropriateness to situation, consistency with mood, congruency with thought content.
● Fluctuations: Labile, even.
● Range: Broad, restricted.
● Intensity: Blunted, flat, normal intensity.
● Quality: Sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious,
animated, irritable.

I. THOUGHT PROCESS OR THOUGHT FORM (Observed/Inquired) logic, relevance, organization, flow

and coherence of thought in response to general questioning during the interview. - Possible descriptors:
● Linear, goal-directed, circumstantial, tangential, loose associations, incoherent, evasive, racing,
blocking, perseveration, neologisms.
● Observe if pt’s verbalizations make sense.
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J. THOUGHT CONTENT (Observed/Inquired)

● “Ano-ano man tim ginhhuna huna kun naabat ka hin lungkot o kauriton?”
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● “Ano man na mga butang it ada haim huna huna yana?”
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● “Naoobserbaran mo ba haim kalugaringon na nagpipinanhuna huna la hin bis ano? Ano man ito
na mga butang na imo nahhuna hunaan?”
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● “Mayda ba mga butang na imo nahhuna hunaan sugad hin mga imahe na makuri mawara haim
huna huna?”
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● “Mayda ba nimo yana kinakahadlukan nga butang?”
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● “Mayda ba nimo mga kalugaringon nga tinutuohan na diri mo la ginyayakan ha iba na tawo?”
(Delusions are fixed, false, unshared beliefs.)
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● “Inabat ka na ba na hin bagan iba ka ha iba na tawo nga nakapalibot haimo?
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● “Haimo pagkita it mga butang ba kay bagat diri tuod haimo?”
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 ● “Haimo pag abat, mayda ba tawo nga karuyag ka pasakitan?”
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● [In response to something the patient says] “Ano man it ibig sabihin nimo hitot?”
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● “Haimo pagobserbar, mayda ba panahon na naabat ka nga it iba na tawo nakawat hit imo mga
ideya? o di ngani nabutang mga butang na hurunaon haimo huna huna? Naabat ka ba na tim
mga huna huna nababaruan han iba?
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● “Do you ever see (visual), hear (auditory), smell (olfactory), taste (gustatory), and feel (tactile)
things that are not really there, such as voices or visions?” (Hallucinations are false perceptions)
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● “Do you sometimes misinterpret real things that are around you, such as muffled noises or
shadows?” (Illusions are misinterpreted perceptions)
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K. SUICIDALITY AND HOMICIDALITY (Inquired)

Suicidality – Possible questions for patient:
a. “Nahingada ka na ba ha punto han imo kinabuhi nga inabat ka nadiri ka na mabuhi pa? O
ginhingyap na mamatay nala?
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b. “Nakahuna-huna ka na ba nga ikaw mismo magkuwa nim kinabuhi? Kun oo, aanhon mo man?“
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c. “Ano man ha imo pagkita it mananabo katima nim mawara/mamatay?”
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Homicidality – Possible questions for patient:
d. “Do you think about hurting others or getting even with people who have wronged you?”
e. “Have you had desires to hurt others? If so, how?”

L. INSIGHT AND JUDGMENT (Observed/Inquired)

“What brings you here today?” / “Kayano ka man nahingadi?
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“What seems to be the problem?” / “Ano man it imo ginpproblema?”
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“What do you think is causing your problems?” / “Ano man haimo pagkita an rason han imo mga
problema?
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“How do you understand your problems?” / “Gaano mo naiintindihan imo problema?”
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“How would you describe your role in this situation?” / “Paano mo man masasaysay an imo papel hini na
sitwasyon/ problema?
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“Do you think that these thoughts, moods, perceptions, are abnormal?” / “Para ba haimo ini na mga
huna-huna ngan pinapan-abat kay diri normal?”
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“How do you plan to get help for this problem?” / “Ano man imo plano para mabuligan ka hini na imo
problema?”
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“What will you do when it occurs?” / “Ano man imo hihimuon kun inabot na an bulig?”
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“How will you manage if it happens?” /
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 “If you found a stamped, addressed envelope on the street, what would you do with it?” / “Kun kumita ka
hin usa ka bag ha kalsada nga bagan nabayaan, ano man imo hihimuon?”
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“If you were in a movie theater and smelled smoke, what would you do?” / “Kun nakadto ka hin sulod han
sinehan tas bumaho ka hin maaso-aso bagan may nasusunog mag aano ka man?”
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M. ATTENTION SPAN (Observed/Inquired)

● Attend, concentration, distractibility.
● Digit Span (forward and reverse) - Suggested patient instructions:
a. “Mayda ako iyayakan na mga numero haimo, tapos imo hira yayaknon pabalik
haakon, una anay kay sunod sunod, katapos kay tipabalik liwat.
- 2,5,7 (forward) 7,5,2 (backwards) dos, singko, syete/ syete, singko, dos
- 1,4,6,7,9,5,2,8 (forward) 8,2,5,9,7,6,4,1 (backwards) piso, quatro, sais, syete,
nuybe, singko, dos, otso / otso, dos, singko, nuybe, syete, sais, quatro,
piso.
● Spelling Backwards - Suggested patient instructions:
a. “Yana liwat kay magsspelling kita. Spell daw hin “mundo”. Yana pabalik naman an
pagspell. “odnum”
● Calculations - Suggested patient instructions:
a. “Kun mayda ka baynte tas inibanan hin singko han cashier, pira man imo sukli?” kinse
b. “Kun hito na kinse gindugngan naton hin dies pira naman?” baynte singko
c. “Kun an baynte singko gin divide ha lima pira naman?” lima
d. (Serial 7’s) “Starting with 100, subtract 7 from 100, and then keep subtracting 7 from
that number as far as you can go.”
e. (Serial 3’s) “Starting with 20, subtract 3 from 20, and then keep subtracting 3 from that
number as far as you can go.” [Monitor for speed, accuracy, effort required, and
monitor patient reactions to the request]
f. “Add these numbers: (15 + 12 + 7)”
g. “Multiply these numbers: (25 x 6)”
h. “If something costs 78 cents and you give the cashier one dollar, how much change
should you get back?”

N. MEMORY (Observed/Inquired)
● Recent Memory – Possible questions for patient:
“What is my name?” / “Ano imo ngaran?
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“What medications did you take today?” / “Ano man imo kinaon/tinumar yana na adlaw?”
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“What time was your appointment with me for today?”/ “Ano nga oras man kita nag istorya yana?”
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● Remote Memory – Possible questions for patient:
“Where were you when President Kennedy was shot?” (For patients over 40)
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“What is your Social Security number?”
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“What were the dates of your graduation from high school, college, graduate school?”
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“When and where did you get married?”
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● Immediate Memory (also see XIII.-A. above) and New Learning - Suggested patient instructions:
“Mayda ako iyayakan na tulo na mga pulong na iyayakan haimo ngan imo ito hira iyayakan
balik haakon, katima hin lima kaminutos. (pula, lamesa, kabayo) after 5 minutes "Sige
ipanyakan haakon an mga pulong.
[Monitor accuracy of response, awareness of whether responses are correct, tendency to
confabulate or substitute other words, ability to correct themselves with category clue and
multiple choice].
 O. INTELLECTUAL FUNTIONING (Observed/Inquired)
Information and Vocabulary - Suggested patient instructions:
a. "Tagi daw ako lima nga lugar didi ha Tacloban."
b. "Tagi daw ako hin lima liwat na bansa ha kalibutan."
c. "Hino man liwat an presidente han pilipinas yana? Vice president, mayor?"
d. Grade school level, high school level, fluent, consistent with education.
Abstraction - Possible questions for patient:
1. Similarities – “How are the following items similar?” "Ano man it pagkakaparehos hin…"
● "Mansanas ngan orange"” (round ~concrete, fruit ~abstract)
● "Lingkuranan ngan lamesa" (made of wood ~concrete, furniture ~abstract)
● “a watch and a ruler” (measurement instruments ~abstract)
2. Proverbs – “How would you describe the meaning of the following sayings?”
● "Ginsimo an grasya, kahuman nagnginanga."
● "An nahadlok hin halas, diri angay maglinakat hin kagubatan"
● "Diri tanan na kaupayan, may dara nga katam-isan"

THE CAGE SCREENING TOOL

● “Have you ever felt that you should Cut down on your drinking?”
● “Have people Annoyed you by criticizing your drinking?”
● “Have you ever felt bad or Guilty about your drinking?”
● “Have you ever had a drink first thing in the morning to steady you nerves or get rid of a
hangover (Eye-opener)?”

● Scoring: Two or more positive responses correlate with substance abuse.

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