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Mental Status Examination Form

This document contains a mental status examination form used to assess and document a patient's mental state. It includes sections to record personal data, general description of behavior, emotional state, neurovegetative functions like sleep and appetite, speech, thought processes, perception, sensorium, cognition, judgment and insight. The examiner indicates their observations and impressions in each section to evaluate the patient's mental status and arrive at relevant DSM diagnoses.

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Lm Gregorio Constantino
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1K views10 pages

Mental Status Examination Form

This document contains a mental status examination form used to assess and document a patient's mental state. It includes sections to record personal data, general description of behavior, emotional state, neurovegetative functions like sleep and appetite, speech, thought processes, perception, sensorium, cognition, judgment and insight. The examiner indicates their observations and impressions in each section to evaluate the patient's mental status and arrive at relevant DSM diagnoses.

Uploaded by

Lm Gregorio Constantino
Copyright
© Attribution Non-Commercial (BY-NC)
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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MENTAL STATUS EXAMINATION

PERSONAL DATA:
Name: Date:
Address: Time
Age: Occupation:
Nationality: Religion:
Date of Admission: Reason of Admission:
Medical Diagnosis:
Attending Physician:

I. GENERAL DESCRIPTION

Behavior & Psychomotor Activity

A. General Mobility: Normal

a. Posture & Gait

Justification: assistance.

b. Action & Gesture

( ) Normal ( ) Inappropriate

Justification:
c. Facial Expression

( ) smiling ( ) Worried ( ) Sad

( ) Ecstatic ( ) Tense ( ) Tearful

( ) Happy ( ) Frightening ( ) Distant

( ) Angry ( ) Suspicious

Justification:

B. Behavior

( ) Depressed ( ) Impulsive ( ) Angry

( ) Embarrassed ( ) Negativistic ( ) Seductive

( ) Indifferent ( ) Withdrawn ( ) Manic

Justification:

C. NURSE- PATIENT INTERACTION

a. Attention

( ) Cooperative ( ) Uncooperative

( ) Intitially ( ) Lately ( ) All through out

Justification:

b. Quality

( ) Warm ( ) Distant ( ) Dependent

( )Hostile ( ) Suspicious ( ) Talkative


Justification:.

II. EMOTIONAL STATE & REACTION MOOD

a. Mood

( ) Depressed ( )Angry ( ) Frightened

( )Anxious ( )Suspecious ( ) Talkative

Justification:

b. Affect

( ) Appropriate ( ) Inappropriate

Justification:

c. Quality

( ) Flat ( ) Blunted

III. NEUROVEGETATIVE FUNCTION

A. Sleep

( ) Normal ( ) Hypersomnia

( ) Early Insomnia ( ) Late Insomnia


( ) Mixed Insomnia

Justification:

B. Appetite

( ) Normal ( ) Increased ( ) Decreased

Justification:

C. Weight

( ) Increased ( ) Decreased ( ) Not Changes

Justification:

D. Diurnal Variation

E. Libido

IV. Speech & Stream of Talk

A. Character

( )Spontaneous ( )Deliberate ( ) Loud ( ) Talkative

( )Whispered ( ) Mumbled ( )Hesitant ( ) Pressured

Justification:
B. Accessibility

( )Good ( )Defensive ( ) Fair ( ) Mute

Justification:

C. Organization of Thoughts

( )Relevant ( )Irrelevant ( ) Circumstantial

( )Tangential

Justification:

V. Perception

( ) Present ( ) Absent

Justification:

VI. Thought

A. Delusion

( ) Present ( ) Absent

Justification:

B. Suicidal Potential
( ) Present ( ) Absent

Justification:

C. Homicidal Potential

( ) Present ( ) Absent

Justification:

VII. Sensorium & Cognition

A. Orientation

( ) Time

Justification: ( impaired/ Unimpaired)

( ) Place

Justification: ( impaired/ Unimpaired)

( ) Person
Justification: ( impaired/ Unimpaired)

B. Memory

( ) Remote

Justification: ( impaired/ Unimpaired)

( ) Recent

Justification: ( impaired/ Unimpaired)

( ) Recent Past

Justification: ( impaired/ Unimpaired)

( ) Immediate

Justification: ( impaired/ Unimpaired)

C. Attention Span
( ) Good ( ) Fair ( ) Poor

Justification:

D. Calculation:

E. Spelling

A. Abstract Thinking Ability

I. Judgment

( ) Impaired ( ) Unimpaired

Justification:

Insight

( ) Impaired ( ) Unimpaired

Justification:
II. Summary of Mental Status

A. Disturbances in:

( ) General Description

( ) Emotional State & Reaction Mood

( ) Neurovegetative Function

( ) Speech & Steam of Talk

( ) Perception

( ) Thought

( ) Sensorium & Cognition

( ) Judgement & Insights

Diagnostic Category

( ) Pschotic ( ) Non- Psychotic

Justification:

B. DSM IV Diagnosis

Axis I

Axis II

Axis III

Axis IV

Axis V

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