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Democrito O. Plaza Memorial Hospital Patin-Ay, Prosperidad, Agusan Del Sur Mental Health Gap Action Programme (Mhgap) Consultation Record

This document contains a consultation record for a patient mental health assessment at the Democrito O. Plaza Memorial Hospital. It includes sections for the patient's personal details, reason for visit, mental status examination, physical examination, diagnosis, and attending physician signature. The mental status examination evaluates the patient's appearance, speech, eye contact, mood, affect, cognition, perception, thoughts, behavior, insight, and judgment. The physical examination covers vital signs, general survey, and specific body systems.

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Cristian Louie Bagang
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122 views2 pages

Democrito O. Plaza Memorial Hospital Patin-Ay, Prosperidad, Agusan Del Sur Mental Health Gap Action Programme (Mhgap) Consultation Record

This document contains a consultation record for a patient mental health assessment at the Democrito O. Plaza Memorial Hospital. It includes sections for the patient's personal details, reason for visit, mental status examination, physical examination, diagnosis, and attending physician signature. The mental status examination evaluates the patient's appearance, speech, eye contact, mood, affect, cognition, perception, thoughts, behavior, insight, and judgment. The physical examination covers vital signs, general survey, and specific body systems.

Uploaded by

Cristian Louie Bagang
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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DEMOCRITO O.

PLAZA MEMORIAL HOSPITAL


PATIN-AY, PROSPERIDAD, AGUSAN DEL SUR
MENTAL HEALTH GAP ACTION PROGRAMME (mhGAP)

CONSULTATION RECORD

LAST NAME: DATE: TIME: PATIENT’S RECORD No:

FIRST NAME: AGE: SEX: STATUS: RELIGION:


[]M []F
MIDDLE NAME: DATE of BIRTH: NATIONALITY: TEL. NO.:

ADDRESS:

BROUGHT BY: [ ] RELATIVES [ ] GUARDIAN [ ] POLICE[ ] ALONE [ ] OTHERS: ___________________

CONDITION on ARRIVAL:
Medical Assessment: [ ] Emergency [ ] Non-Emergency [ ] Dead on Arrival (DOA)
Psychiatric Assessment: [ ] Highly Disturbed [ ] Disturbed [ ] Manageable
HISTORY of PRESENT ILLNESS:
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MENTAL STATUS EXAMINATION:
OBSERVATION
Appearance □ Neat □ Disheveled □ Inappropriate □ Bizarre □ Other
Speech □ Normal □ Tangential □ Pressured □ Impoverished □ Other
Eye Contact □ Normal □ Intense □ Avoidant □ Other
Motor Activity □ Normal □ Restless □ Tics □ Slowed □ Other
Affect □ Full □ Constricted □ Flat □ Labile □ Other
MOOD
□ Euthymic □ Anxious □ Angry □ Depressed □ Euphoric □ Irritable □ Other
Comments:
COGNITION
Orientation Impairment □ None □ Place □ Object □ Person □ Time
Memory Impairment □ None □ Short-Term □ Long-Term □ Other
Attention □ Normal □ Distracted □ Other
PERCEPTION
Hallucinations □ None □ Auditory □ Visual □ Other
Other □ None □ Derealization □ Depersonalization
THOUGHTS
Suicidality □ None □ Ideation □ Plan □ Intent □ Self-Harm
Homicidality □ None □ Aggressive □ Intent □ Plan
Delusions □ None □ Grandiose □ Paranoid □ Religious □ Other
BEHAVIOUR
□ Cooperative □ Guarded □ Hyperactive □ Agitated □ Paranoid
□ Stereotyped □ Aggressive □ Bizarre □ Withdrawn □ Other
INSIGHT □ Good □ Fair □ Poor Comments:
JUDGMENT □ Good □ Fair □ Poor Comments:

PHYSICAL EXAMINATIONS
Vital Signs: BP: _____ HR: _____ RR: _____ T: _____ O2 Sat.: _____
General Survey: __________________________________________________________________________
HEENT: _________________________________________________________________________________
Chest and Lungs: _________________________________________________________________________
Heartt: _________________________________________________________________________________
Abdomen: _______________________________________________________________________________
Extremities: ______________________________________________________________________________
Genitalia (if indicated): ____________________________________________________________________
Lymphatics: ______________________________________________________________________________
NUROLOGICAL EXAMINATION
Cerebral Dominance: _____________________________________________________________________
Cerebellar Function: ____________________________________________________________________
Cranial Nerves:
I: IX, X :
II: XI:
III, IV, VI: XII:
V: Motor Strength:
VII: Sensory perception:
VIII: Reflexes:
DIAGNOSIS:
Psychiatric: _____________________________________________________________________________
Medical: _____________________________________________________________________________
Others: _____________________________________________________________________________

________________________
ATTENDING PHYSICIAN

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