MENTAL STATUS EXAMINATION

IDENTIFICATION DATA OF PATIENT

1. NAME:

2. AGE/SEX:

3. RELIGION:

4. MARITAL STATUS:

5. EDUCATIONAL QUALIFICATION:

6. OCCUPATION:

7. DATE OF ADMISSION:

8. FAMILY TYPE:

9. DIAGNOSIS:

10.DOCTOR:
 MENTAL STATUS EXAMINATION

I. GENERAL APPEARANCE AND BEHAVIOUR(GAAB):-

a) Facial expression:

b) Posture:

c) Mannerism:

d) Eye-to eye contact:

e) Rapport:

f) Behaviour:

g) Dressing and Grooming:

h) Physical Features:
 II. PSYCHOMOTOR ACTIVITY:-

III. SPEECH:-
a) Coherence:

b) Relevance:

c) Volume:

d) Tone:

e) Manner:

f) Reaction Time:

IV. THOUGHT:

a) Form of thought:
 b) Stream of thought:

c) Content of thought:

 Delusions:

 Obsessions:

 Phobia:

 Preoccupation:

 Fantasy:

IMPRESSION:-

V. MOOD AND AFFECT:

a) Appropriate/Inappropriate:
 b) Pleasurable affect:

c) Un-pleasurable affect:

d) Other affects:

IMPRESSION:-

VI. DISORDERS OF PERCEPTION:-

a) Illusion:

b) Hallucinations:
 c) Others:

IMPRESSION:

VII. COGNITIVE FUNCTIONS:

a) Attention and Concentration:

 Method of testing:

 Serial substraction:
IMPRESSION:

b) Memory:
 Immediate-

 Recent-

 Remote-

IMPRESSION:-
 c) Orientation:
 Time-

 Place-

 Person-

IMPRESSION:

d) Abstraction:

e) Intelligence and General Information:

 f) Judgement:
 Personal-

 Social-

 Test

IMPRESSION:

g) Insight:

IMPRESSION:
VIII. GENERAL OBSERVATIONS:
a) Sleep-

b) Episodic Disturbances:

IX. SUMMARY:-

X. CLINICAL DIAGNOSIS:-

XI. EVALUATION:-