MENTAL STATUS EXAMINATION

Name: _____________________________ Date: _________________

Birthday: ____________________ Age: ________

I. GENERAL DESCRIPTION

A. Appearance

Dress and Grooming Physical Characteristics Posture Gait

 Meticulous  Thin
 Fat  Straight  Slow
 Skilfully Applied
 Normal
 Garish  Slump  Fast
 Self-neglect *  Disabilities
Specify: _____________  Normal
 Neat
 Unconventional Voice Quality
 Fashionable  Strong
 Weak
 Hoarse
 Halting

Remarks:
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B. Attitude and Interpersonal Style

 Cooperative  Evasive
 Uncooperative *  Guarded Facial Expression
 Hostile *  Sullen
 Bland
 Inappropriate  Passive  Flat
Boundaries *  Manipulative  Mobile
 Seductive  Contemptuous
 Playful  Demanding
 Ingratiating  Withdrawn

Remarks: _______________________________________________________________
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C. Behavior and Psychomotor Activity

 Seated Quietly  Motor Hyperactivity *

 Hyperactive  Motor Retardation *
 Agitated  Mannerisms and Posturing *
 Combative  Tension *
 Awkward  Severe Akathisia *
 Rigid  Tardive Dyskinesia *
 Mannerisms  Catatonic Behavior *
 Posturing
 Tics and Twitches
 Stereotypes
Remarks: _______________________________________________________________
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D. Speech and Language

 Pressured Aphasia *
 Monotonous  Global Aphasia (speaking, comprehension)
 Emotional  Broca's Aphasia (speaking)
 Accented  Wernicke's Aphasia (comprehension)
 Impoverished  Dysarthria
 Neologisms *  Perseveration
 Stereotypy

Remarks: _______________________________________________________________
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II. EMOTIONS

A. Mood

 Hopeless
 Euthymic  Empty
 Guilty
 Expansive
 Irritable
 Euphoric  Angry
 Enraged
 Anxious  terrified
 Sullen
 Depressed
 Dejected

Remarks: _______________________________________________________________
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B. Affect

 Broad  Emotional Withdrawal *

 Appropriate  Excitement *
 Constricted  Full range of Affect *
 Blunted *
 Flat
 Labile
 Anhedonic

Remarks: _______________________________________________________________
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C. Neurovegative Signs of Depression

 Initial Insomnia
 Middle Insomnia
 Terminal Insomnia
 Hypersomnia

Remarks: _______________________________________________________________
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III. COGNITIVE FUNCTIONING

A. Orientation and Level of Consciousness

 Lethargy Orientation
 Obtundation  Date
 Stupor  Place
 Coma  Identity

Remarks: _______________________________________________________________
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B. Attention and Concentration

Attention Concentration
 Good  Good
 Poor  Poor

Remarks: _______________________________________________________________
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C. Memory
 Short-term Memory  Anterograde Amnesia
 Long-term Memory  Retrograde Amnesia
 Amnesia  Head Injuries
 Transient Global Amnesia

Remarks: _______________________________________________________________
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D. Ability to Abstract and Generalize

 Proverbs

 Similarities and Differences

Remarks: _______________________________________________________________
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E. Information and Intelligence

IV. THOUGHT AND PERCEPTION

A. Disordered Perceptions
 Illusions  Depersonalization
 Hallucinations *  Derealization

Remarks: _______________________________________________________________
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B. Thought Content
 Thought Withdrawal  Somatic Delusions
 Thought Insertion  Delusional Guilt
 Thought Broadcast  Nihilistic Delusions
 Suspiciousness *  Ideas of Inference
 Grandiose Delusions *  Ideas of Reference
 Magical Thinking *

Remarks: _______________________________________________________________
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C. Thought Processes
 Flow of Ideas
 Spontaneous
 Goal Directed
 Impoverished
 Racing Thoughts
 Blocking  Illogical
 Circumstantial  Incoherent
 Perseverative  Neologism
 Flight of Ideas  Distractible
 Loose Associations  Clang Association
 Tangentiality
 Overvalued Ideas
 Conceptual
Disorganization *

Remarks: _______________________________________________________________
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D. Preoccupations
 Somatic Preoccupation  Compulsions
 Obsessions  Phobias

Remarks: _______________________________________________________________
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V. SUICIDALITY, HOMOCIDALITY AND IMPULSE CONTROL
 Suicidality and Homocidality

 Impulse Control

VI. INSIGHT AND JUDGEMENT

 Insight

 Judgement