MENTAL STATUS EXAMINATION

NAME: AGE: GENDER: [M] [F]

1. General Description: 7. Concentration and Attention:

a. Reading and writing:
2. Mood and Affectivity: Intact, Impaired:
b. Visual spatial ability:
3. Speech Characteristics: Intact, Impaired:
c. Abstract thought:
4. Perception: Intact, Impaired:
d. Serial 7’s:
a. Hallucinations: no yes Intact, Impaired:
b. Illusions: no yes
8. Judgement and Insight:
5. Thought Content and Mental Trends
a. Judgement: good, poor
a. Flight of Ideas: no yes
b. Insight: denial, aware, intellectual
b. Looseness of association: no yes insight, true emotional insight
c. Circumstantiality: no yes
d. Tangentiality: no yes
e. Delusions: no yes
f. Preoccupations: no yes
g. Suicidal: no yes

6. Sensorium and Cognition

a. Consciousness: alert, fugue, cloudy,

somnolence, stupor, coma
b. Oriented to time: no yes
c. Oriented to person: no yes
d. Oriented to place: no yes
e. Remote memory:
Intact, Impaired:
f. Recent past memory:
Intact, Impaired:
g. Recent memory:
Intact, Impaired:
h. Immediate retention and recall:
Intact, Impaired:
i. Confabulation: no yes