Mental Status Examination Template

Mental Status Examination upon Initial Introduction and Succeeding VisitsPSYCHIATRIC HISTORY AND ASSESSMENT TOOLIdentifying/Demographic Information

Name: Room No.

Primary Care Provider:

DOB: Age: Sex:

Race: Ethnicity:

Marital Status: No. Marriages:

If married/divorce/separated/widowed, how long?

Occupation/School (Grade):

Highest Educational Level:

Religious Affiliation: Roman

City of Residence:

Name/Phone # of Significant Other:

Primary Dialect/Language Spoken:

Accompanied by:

Admitted from:

Previous Psychiatric Hospitalizations (#):

Chief Complaints (in patients own words):

DSM-IV TR Diagnosis (Previous/Current):

Nursing Diagnosis:

Family Members/Significant Others Living In Home

NAMERELATIONSHIPAGEOCCUPATION/GRADE

Family Members/Significant Others Not In Home

NAMERELATIONSHIPAGEOCCUPATION/GRADE

Children

NAMEAGELIVING AT HOME?

Past Psychiatric Treatment/Medications

It is important to obtain a history of any previous psychiatric hospitalizations, the number of hospitalizations and dates, and to record all current/past psychotropic medications as well as other medications the client may be taking. Ask the client what has worked in the past, and also what has not worked for both treatment and medications.

Inpatient Treatment

Facility/LocationDates From/ToDiagnosisTreatmentsResponse (s)

Outpatient Treatment/Services

PsychiatristLocationDiagnosisTreatmentResponse (s)

Psychotropic Medications (Previous Treatments)

NameDose/DosagesTreatment LengthResponseComments

Current Psychotropic Medications/Other Medications

Current Psychotropic Medications

NameDose/DosagesDate StartedResponse (s)Serum Levels

Other Current Medications/Herbals/and OTC medications

NameDose/DosagesDate StartedResponse (s)Serum Levels

MEDICAL HISTORY

Temp: Pulse: RR: BP:

Height: Weight:

Cardiovascular (CV) Does client have or ever had the following disorders/symptoms? Include date

Hypertensions: Murmurs: Chest Pain (Angina):

Palpitations/Tachycardia: Shortness of Breath:Ankle Edema/ CHF:

Fainting/Syncope: Myocardial Infarction: High Cholesterol:

Leg Pain (Claudication):Arrhythmias:Other CV Diseases:

Heart Bypass:Angioplasty:Other CV Surgery:

Central Nervous System (CNS) Does client have or ever had the following disorders/symptoms? Include date

Headache:Head Injury:Tremors:

Dizziness/Vertigo:Loss of Consciousness: Stroke:

Myasthenia Gravis:Parkinsons Disease:Dementia:

Brain Tumor:Seizure Disorder:Multiple Sclerosis:

TIAs:Other:Surgeries:

Dertmatological/Skin Does client have or ever had the following disorders/symptoms? Include date

Psoriasis:Hair Loss: Itching:

Rashes:Acne:Other/Surgeries:

Endocrinology/ Metabolic Does client have or ever had the following disorders/symptoms? Include date

Polydipsia: Polyuria:Diabetes Type 1 or 2:

Hyperthyroidism:Hypothyroidism:Hirsutism:

PCOs:Other:Surgeries:

Eyes, Ears, Nose Throat

Eye Pain: Halo around Light Source:Blurring:

Red Eye: Double Vision:Flashing Lights/Floaters:

Glaucoma:Tinnitus:Ear Pain/Otitis Media:

Hoarseness:Other:Other Surgeries:

Gastrointestinal

Nausea and Vomiting: Diarrhea: Constipation:

GERD:;Crohns Disease: Colitis:

Colon Cancer:Irritable Bowel Syndrome:Other/Surgeries:

Genito-urinary/Reproductive

Miscarriages Y/N: # and when?Abortions? Y/N: # and when?

Nipple Discharge: Amenorrhea: Gynecomastia:

Lactation: Dysuria: Urinary Incontinence:

Pregnancy Problems: Postpartum Depression: Sexual Dysfunction:

Prostate Problems: Menopause: Fibrocystic Disease:

Penile Discharge: UTI: Pelvic Pain:

Renal Disease: Urinary Cancer: Breast Cancer:

Other/SurgeriesOther Gynecologic CancerOther:

Respiratory

Chronic Cough: Sore Throat: Bronchitis:

Asthma: COPD: Pneumonia:

Cancer (Lung/Throat): NONESleep Apnea: Other/ Surgeries

Other Questions

Allergies (food/environment/pet/contact):

Diet:

Drug Allergies:

Accidents:

High Prologed Fever:

Childhood Illness:

Fractures:

Menses Began:

Birth Control:

Disabilities (Hearing/Speech/Movement):

Tobacco Use:

Pain (describe/location/length of time (over or under 3 months)/ severity between 1 (least) and 10 (worst)/Treatment:

Family History

Mental Illness: Schizophrenia, Paranoid (Paternal side)

Medical Disorders:

Substance Abuse (please note who in the family has a problem/disorder):

Substance Abuse

Prescribed Drugs

NameDosageReason

Street Drugs

NameAmount/DayReason

Alcohol

NameAmount/DayReason

SUBSTANCE HISTORY AND ASSESSMENT TOOL

1. When you were growing up, did anyone in your family use substances (alcohol or drugs) if yes, how did the substance use affect the family?

2. When (how old) did you use your first substance (e.g., alcohol, cannabis) and what was it?

3. How long have you been using a substance (s) regularly? Weeks, months, years?

4. Pattern of abuse

a. How much and how often do you use?

b. Where are you when you use substances and with whom?

5. When did you last use; what was it and how much did you use?

6. Has substance caused you any problems with family, friends, job, school, the legal system? If yes, describe:

7. Have you ever had an injury or accident because of substance abuse? If yes, describe:

8. Have you ever been arrested for a DUI because of your drinking or other substance use?

9. Have you ever been arrested or placed in jail because of drug or alcohol?

10. Have you ever experience memory loss the morning after substance abuse (cant remember the night before?) Describe the even and feelings about the situation:

11. Have you ever tried to stop your substance use? If yes, why were you not able to stop? Did you have any physical symptoms such as shakiness, sweating, nausea, headaches, insomnia, or seizures?

12. Describe a typical day in your life:

MENTAL STATUS ASSESSMENT AND TOOL

Presenting Problem:

APPEARANCE

DescribeDay 1Day 2Day 3Day 4Day 5

Grooming/Dress

Hygiene

Eye Contact

Posture

Identifying features (Marks/scars/Tattoos)

Appearance versus stated age

Over all Appearance

BEHAVIOR/ACTIVITY

Check if presentDay 1Day 2Day 3Day 4Day 5

Hyperactive

Agitated

Psychomotor retardation

Calm

Tremors

Unusual movements/gestures

Catatonia

Akathisia

Rigidity

Facial Movements(jaw/lip smacking)

Others: (Specify)

SPEECH

DescribeDay 1Day 2Day 3Day 4Day 5

Slow/Rapid:

Pressured:

Tone:

Volume (loud/soft)

Fluency (mute/hesitation/latency of response):

Other specify:

ATTITUDE

Is client: (Check if Present)Day 1Day 2Day 3Day 4Day 5

Cooperative

Uncooperative

Warm/Friendly

Distant

Suspicious

Combative

Guarded

Aggressive

Hostile

Aloof

Apathetic

Other specify:

MOOD AND AFFECT

Is client: (Check if Present)Day 1Day 2Day 3Day 4Day 5

Elated

Sad

Depressed

Irritable

Anxious

Fearful

Guilty

Worried

Angry

Hopeless

Labile

Mixed (Anxious and Depressed)

Is clients Affect:

Flat

Blunt or Diminished

Appropriate

Inappropriate/Incongruent

Other Specifiy:

THOUGHT PROCESS

(Check if Present)Day 1Day 2Day 3Day 4Day 5

Concrete Thinking

Circumstantiality

Tangentiality

Loose Association

Echolalia

Flight of Ideas

Perseveration

Clang association

Blocking

Word Salad

Derailment

Others Specify:

THOUGHT CONTENT

Does Client have: (Check if Present)Day 1Day 2Day 3Day 4Day 5

Delusions:

a. Grandiose

b. Persecutory

c. Reference

d. Somatic

Suicidal Thoughts

Homicidal Thoughts

If homicidal, towards whom?

Obsessions

Paranoia

Phobias

Magical Thinking

Poverty of Speech

Others Specify:

PERCEPTUAL DISTURBANCES

Day 1Day 2Day 3Day 4Day 5

Is client experiencing: (Check if Present)

Visual Hallucinations

Auditory Hallucinations

a. Commenting

b. Discussing

c. Commanding

d. Loud

e. Soft

f. Other

Other halluncination (olfactory/tactile)

Illusions

Depersonalization

Other Specify

MEMORY/COGNITIVE

Day 1Day 2Day 3Day 4Day 5

Orientation (Yes/No)

a. Time

b. Place

c. Person

Memory (Good/Poor)

a. Recent

b. Remote

c. Confabulation (Y/N)

Level of Alertness

INSIGHT and JUDGEMENT

Day 1Day 2Day 3Day 4Day 5

Insight (Awareness of the nature of the Illness)

Judgement (Good/Poor)

Impulse Control (Good/Poor)

Concentration (Good/Poor)

Attention (Good/Poor)

Other Specify:

A. Mental Status ExamDay 1Day 2Day3Day 4Day 5

A. General appearance

B. Posture

C. Behaviors

D. Distant

A.1 SpeechDay 1Day 2Day 3Day 4Day 5

Soft

Loud

Hesitant

Slurred

Superior

Humor

Frightened

A.2 Does his style and vocabulary covey?Day 1Day 2Day 3Day 4Day 5

Coyness

Suspiciousness

Arrogance

Secrecy

Superiority

Humor

Fear

A.3 Stream of talkDay 1Day 2Day 3Day 4Day 5

Spontaneous

Deliberate

Pressured

A.3 Organization of TalkDay 1Day 2Day 3Day 4Day 5

Relevant

Irrelevant

Incoherent

Loose Associat ion

Flight of Ideas

Tangentiality

Circumstantiality

Perseveration

Clang Association

Neologism

Echolalia

Echopraxia

A.5 Mood and AffectDay 1Day 2Day 3Day 4Day 5

1. Mood

Euthymic

Depressed

Euphoric

2. Affect

Flat

Blunt

Angry

Elated

Anxious

Fearful

A.6 Range of Affective ExpressionsDay 1Day 2Day 3Day 4Day 5

Consistent

Labile

Anhedonic

Appropriate to the situation and feelings verbalized

A.7 PerceptionDay 1Day 2Day 3Day 4Day 5

Hallucination

Auditory

Visual

Olfactory

Tactile

Delusion

Grandeur

Persecutory

Reference

others

Illusion

Derealization

Identification

Thought broadcasting

Deje Vu

Jamis Vu

A.8 Organization and MemoryD1D2D3D 4D5

1. Identifies date correctly

2. Estimates time and day

3. Knows where she is

4. Knows the examiner

5. Recalls activities done within 24hrs.

6. Recalls activities done within one week

A.9 Neuro-vegetative FunctioningD1D2D3D 4D5

Sleep and Rest Pattern

Normal sleep

Early morning awakening

Middle night awakening

Hyper insomnia

Difficulty of falling asleep

Interrupted sleep

A.10 EliminationDay 1Day 2Day 3Day 4Day 5

Bowel

Bladder

A.11 Abstract Thinking AbilityDay 1Day 2Day 3Day 4Day 5

Abstract thinking ability

A.12 JudgmentDay 1Day 2Day 3Day 4Day 5

Judgment