IDENTIFYING DATA:

This section is brief, one or two sentences, and typically includes the patient’s name, age, sex, marital status
(or significant other relationship), race or ethnicity, and occupation. Often the referral source is also included.

Name:
Age:
Address:
Birth date:

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:

The present illness is a chronological description of the evolution of the symptoms of the current episode.
Include any other changes that have occured during this same time period in the patient’s interests,
interpersonal relationships, behaviors, personal habits and physical health.

Much of the essential information can be derived from open ended questions:

Doc:
“Can you tell me in your own words what brings you here today?”
“Meron pa po ba kayong ibang nararamdaman?”

Leading question examples to help the patient discuss the presenting problems:

Doc:
“Gaano na ho katagal ang sintomas nyo?”
“May pagbabago ba kayong napansin sa sintomas nyo po?”
“Mayroon bang anumang dahilan o sanhi ng paglala ng sintomas nyo?”
“May mga ginagawa po ba kayo upang mapagaan ang sintomas nyo?”

Essential questions to elicit: the length of time of the symptoms, any fluctuations in severity over time,
associated factors, presence or absence of stressors and trigger factors, alleviating factors, coping skills or
treatment for the current episode.

PAST PSYCHIATRIC HISTORY:

In the past psychiatric history, the clinician should obtain information about all psychiatric illnesses and their
course over the patient’s lifetime, including symptoms and treatment. (KAPLAN)

Doc: Nangyari na po ba ito dati? (hx of same s/sx)

If yes:
● Pwede nyo po ba idescribe kung ano yung mga sintomas na naramdaman nyo dati?
● Kailan po ito nangyari? Gano po ito katagal? Ilang beses po ito nangyari?
● Nagkonsulta na po ba kayo sa doktor o psychiatrist? Nasabi po ba ang diagnosis? Ano daw po
ang diagnosis?
● Nagpagamot po ba kayo? Voluntary po ba ito o pinilit lang? Kinailangan po ba na maospital?
● Paano po kayo ginamot? May mga ininom po ba kyong gamot?
● May mga support groups? Vocational training?
● May mga therapy po ba kayo? Electroconvulsive therapy? Light therapy?
○ If yes to meds/ therapy: Gaano po katagal, ano po ang doses? Kelan po hininto? Bakit
hininto? Ano po naramdaman after paginom ng gamot/undergo therapy? May side
effects po ba?
The psychiatrist should also inquire whether a diagnosis was made, what it was, and who made the diagnosis.
Although a diagnosis made by another clinician should not be automatically accepted as valid, it is important
information that can be used by the psychiatrist in forming his or her opinion.

Doc: Nadiagnose na po ba dati ng iba pang sakit? (if yes, ask same questions above)

Doc: Nagpakonsulta na po ba sa psych dati? Ano pong diagnosis?

(if yes, ask same questions above)

Special consideration should be given to establishing a lethality history that is important in the assessment of
current risk. Past suicidal ideation, intent, plan, and attempts should be reviewed including the nature of
attempts, perceived lethality of the attempts, save potential, suicide notes, giving away things, or other death
preparations. Violence and homicidality history will include any violent actions or intent.

Doc: May events po ba na naisip nyo magpakamatay? Ilang beses po?

Sinubukan/ ginawa nyo po ba? Ilang beses?
Gumawa ng suicide notes? Namigay ng gamit? Or other death preparation?
Pano po ang plano? Pano ginawa?

History of nonsuicidal self-injurious behavior should also be covered including any history of cutting, burning,
banging head, and biting oneself. The feelings, including relief of distress, that accompany or follow the
behavior should also be explored as well as the degree to which the patient has gone to hide the evidence of
these behaviors

Doc: Naisipan saktan ang sarili without intention ng suicide?

Naglaslas? Pinaso ang sarili? Inuntog ang ulo? Kinagat or kinurot ang sarili?
Other pananakit sa sarili?

After saktan ang sarili? Ano naramdaman? Umokay po ba kyo? Narelieve?

Sinubukan nyo po ba itaga ung mga bakas ng laslas/paso/kagat/kurot/etc?

Specific questions about domestic violence, legal complications, and outcome of the victim may be helpful in
defining this history more clearly.

Doc: May nangyari po ba na pangaabuso? Pananakit?

Sino ang gumawa? Kaano ano? Kailan? Paano?
Ano ginawa after mangyari? May pinagsabihan?

Substance use/ abuse

Doc: Gumamit na ba ng ipinagbabawal na gamot? Maaring malaman kung anong gamot? Gaano
kadalas siya ginagamit? Gaano katagal na po ang paggamit ng ipinagbabawal na gamot? Paano niyo po siya
ginagamit, iniinom po ba, sinisinghot o pinapadaan sa ugat? Mayroon po ba kayong kasamang gumagamit
nito?
(if patient seems reluctant to share such information specific questions may be helpful)
● Nakagamit na ba ng Marijuana/Shabu/Ecstasy

Doc: Umiinom po ba kayo ng alak? Gaano po kadalas? Araw-araw po ba? Anong klaseng alak po ang
iniinom? Ilang bote/shot ang kadalasang nauubos? Gaano katagal na po kayo umiinom? Habang tumatagal po
ba padami na padami ang volume na gusto niyong inumin para lamang malasing? Kapag itinigil niyo pong
uminom, mayroon po ba kayong nararamdaman na hindi kanais-nais? Maaari ko po bang malaman ang
dahilan ng kadalasang pag-inom ng alak?

CAGE includes four questions: Have you ever Cut down on your drinking? Have people Annoyed you by
criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink the
first thing in the morning, as an Eye-opener, to steady your nerves or get rid of a hangover? The Rapid Alcohol
Problem Screen 4 (RAPS4) also consists of four questions: Have you ever felt guilty after drinking (Remorse),
could not remember things said or did after drinking (Amnesia), failed to do what was normally expected after
drinking (Perform), or had a morning drink (Starter)?

● Pagkatapos niyo po uminom, na-guguilty po ba kayo?

● Naaalala niyo po ba ang mga pangyayari o mga ginawa niyo matapos uminom?
● Hindi niyo po ba nagagawa ang mga normal na bagay matapos uminom?
● Umiinom po ba kayo agad pagkagising sa umaga?

Doc: Mayroon po bang time na kayo ay nakulong dahil sa pag-inom? Gaano po katagal? Nag-gamot na po ba
kayo, nag-rehabilitation, group therapy?

Doc: Kayo po ba ay naninigarilyo? Simula kailan po? Ilang taon na po kayo naninigarilyo? Ilang sticks po kada
araw ang inyong nauubos? Mayroon po ba kayong balak itigil ang paninigarilyo? Ready na po ba kayo itigil
ang paninigarilyo kahit anong oras?

Doc: Kayo po ba ay nagsusugal? Saan niyo po naisusugal ang inyong pera? Casino? Karerahan? Lotto?
Pustahan? Gaano po kadalas? Araw-araw po ba?

Past Medical History

Includes an account of major medical illnesses and conditions as well as treatments, both past and present.
Any past surgeries should be also reviewed. Allergies should be covered. Review of current medications is
very important.

Doc: Meron po ba kayong sakit tulad ng Hypertension? Diabetes? Cancer? Hyper/Hypothyroidism? May mga
iniinom po bang gamot? (not only prescribed even mga OTC drugs, mga vitamins or herbs) (If meron, ask
kung ano, gaano na katagal iniinom, gaano ka compliant with schedules (ask if gaano kadalas sa isang linggo
nila iniinom), may napapansin bang kakaiba after uminom ng gamot (side effects))

Doc: May history na po ba kayo ng operasyon? Kailan at para po saan?

Doc: May mga allergies po ba kayo? Sa pagkain or gamot po? May history of asthma po ba?

Any known history of prenatal or birthing problems or issues with developmental milestones should be noted.
In women, a reproductive and menstrual history is important as well as a careful assessment of potential for
current or future pregnancy.

Doc: Hindi naman po kayo nagbubuntis sa kasalukuyan? Paano niyo po nasabi na hindi kayo buntis?

(if with hx of pregnancy) Doc: Nagkaroon ba kayo ng problema nung nagbubuntis po kayo? (if meron, ask what
was the problem and how she handled it)

Family History
Healthy: age
Deceased: age of death and reason
Doc: Kamusta na po yung tatay niyo po? Ilan taon na po siya? Alam niyo po ba kung paano siya namatay at
ilan taon po siya nun?

Doc: Eh si nanay naman po? Ilan taon na po siya? Paano po siya namatay, ilan taon po siya nun?

Doc: May mga kapatid po ba kayo? Kamusta na po sila?

Doc: Kamusta na po yung lolo at lola niyo po? Ilan taon na po sila? Alam niyo po kung ano po nangyari?

Doc: May alam po ba kayo mga diseases or illnesses sa family niyo po? Katulad po ng Diabetes or
hyperlipidemia or psychiatric disorders po?

Doc: Meron ba sa pamilya ninyo ang nagkaroon o nakakaranas ng parehong sintomas?

Developmental and Social History
Any available information concerning prenatal or birthing history and developmental milestones should be
noted.
Doc: Paano niyo po idedescribe ang pamumuhay niyo nung kabataan? Saan kayo nakatira? Ilan ang mga
kasama mo sa bahay? Kamusta sila? Ilan ang mga naging kaibigan mo? (Childhood history)
Doc: Anong natapos mo sa pag-aaral? Ilan taon ka nagsimulang pumasok sa paaralan? (note any special
education circumstances or learning disorders, behavioral problems at school) Hirap ka bang umintindi ng
lesson? Merong kakaibang mga kinikilos o pag-uugali? Kamusta mga grades? Meron ka bang extracurricular
activities? (Detailed school history)
Doc: Medyo sensitibo ang itatanong ko pero kailangan ko lang itanong kung meron ka bang naranasang
physical o sexual abuse? (Exposure and history or STI) Ilan ang mga naging partners o katalik?
Doc: Ano ang trabaho mo ngayon? Kamusta ang performance mo? Ano ang mga naging trabaho mo?
Kamusta ang relationship mo sa boss at mga katrabaho mo? (Work history)
Doc: Kamusta ka financially? Insurance? (ADD Military history, Marriage & Relationship history, Intimacy &
Sexual behaviors, Legal history- pending charges or lawsuits, Social history, Leisure time activities and how
this has fluctuated over time, Cultural and religious beliefs/practices)

Doc: Ilan ang mga kasama mo sa bahay ngayon? Ano ang source ng drinking water? Ilang beses nagtatapon
ng basura?
Doc: Ano pong favorite niyong ulam? Mahilig po ba kayong uminom ng kape? Umiinom ng alak? Tuwing
kailan? Naninigarilyo? Gaano na katagal? Ilang sticks sa isang araw? Nag-eexercise po kayo? Nakakailang
oras ng tulog kada araw?

Review of Systems
- Attempts to capture any current physical or psychological signs and symptoms not already identified in
the present illness. Particular attention is paid to neurological and systemic symptoms (e.g., fatigue or
weakness). Illnesses that might contribute to the presenting complaints or influence the choice of
therapeutic agents should be carefully considered (e.g., endocrine, hepatic, or renal disorders).
Constitutional symptoms
Doc: May napansin po ba kayong pagbabago sa inyong timbang tulad po ng pagpayat o pagtaba? Meron po
bang ibang nararamdaman kagaya ng panghihina ng katawan, o madalas na pagkapagod? May gana naman
po bang kumain? May pakiramdam po ba na giniginaw o parang mainit po ang katawan ninyo?
Skin
Doc: May napansin po ba kayo sa inyong balat, kung may pamumula, paninilaw o pamumutla ng balat? May
pangagati po ba? Kung meron po, saan banda? May napansin po ba kayo na labis na panunuyo o pagpapawis
ng balat?
HEENT
Doc: Nakakaramdam po ba ng pagsakit ng ulo, pagkahilo? Nakakaramdam po ba kayo na parang umiikot ang
paligid ninyo? Nakakaranas po ba ng pananakit ng mga mata? Panlalabo ng paningin? Pag nakatingin kayo sa
ibang bagay, dumudoble po ba? Madalas po bang magluha ang mga mata? Gumagamit po ba ng salamin
kapag nagbabasa? May nararamdaman po bang masakit sa tenga, kung meron po, aling tenga, kaliwa o
kanan? Nakaranas po ng pagkabingi o may naririnig kayo na parang mahinang tinig sa loob ng tenga? May
napansin po ba kayong lumalabas sa inyong tenga na parang likido? May napansin ba kayong pagbara sa
ilong? Sinisipon po ba? May pananakit po ba sa ilong? May pagdurugo po ba ng ilong? May pagbabago po ba
sa inyong pangamoy? May ramdaman po ba kayo na pananakit ng ngipin o gilagid? May pagdurugo po ba ng
gilagid? May pananakit po ba ng lalamunan?May nararamdaman po bang hirap sa paglunok? May pagbabago
po ba s pagsasalita kagaya ng pamamalat ng boses?
Neck:
Doc: May pananakit po ba sa leeg? Hindi naman po limitado ang paggalaw ng inyong leeg? May napansin ba
kayong bukol sa leeg o may nakapa bang bukol?
Breast:
Doc: May masakit po ba sa dibdib? May napansin po ba kayo o nakapang bukol? May lumalabas po ba sa
inyong utong/nipples?
Respiratory:
Doc: May hirap po ba sa paghinga? Kung may hirap sa paghinga, masakit po ba ang dibdib? May ubo po ba?
Kung may ubo, may lumalabas po ba na phlema? Kung may phlema, anung kulay ng phlema?
Cardiovascular:
Doc: Nakakaramdam po ba ng pagkabog ng dibdib? Nakakaranas po ba ng madaling pagkahapo pag
naglakad sandali? Nakaranas po ba ng panandaliang pagkawala ng malay?
Gastrointestinal:
Doc: Nakakaramdam po ba ng pananakit ng tiyan? Nakararanas po ba ng pagkahilo,pagkaduwal o
pagsusuka? Kung nakaranas ng pagsusuka, anung kulay ng sinuka? Nakaranas po ba ng pagtatae?
Nahihirapan po ba sa pagdumi? May napansing dugo o kulay pula o pangingitim ng dumi?
Genitourinary:
Doc: Nakakaramdam po ba ng hirap sa pag-ihi? Madalas po ang pag-ihi, lalo na sa gabi? Madalas po ba kayo
makaramdam ng pagkabalisawsaw? May nararamdaman po bang sakit sa pag-ihi? May kasama po bang
dugo o kulay pula o kasing kulay ng tsaa ang ihi? May oras po ba na hindi mapigilan ang inyong pag-ihi? May
pangangati po ba sa ari? O may napapansin pong likido na lumalabas sa inyong ari?
Extremities:
Doc: May napansin po ba kayong pamamanas sa braso at binti? May pamamaga po ba o pananakit sa
kasukasuan? Nakakaranas po ba ng paninigas ng mga kalamnan sa braso at binti? Nakakaramdam po ba ng
pamamanhid ng mga kamay o mga paa? Nakakaramdam po ba ng pananakit ng binti tuwing kayo ay
naglalakad? Meron po bang limitasyon sa inyong paggalaw?
Nervous system
Doc: Nakaranas po ba ng pagkawala ng malay o pagkahimatay? Panghihina sa isang parte ng katawan?
Nakakaranas po ba na parang tinutusok-tusok ang ilang bahagi ng katawan? Nakakaranas po ba kayo ng
pagiging makakalimutin o pagkalito?
Hematologic
Doc: May pagkakataon po ba na madali kayong magkapasa sa katawan? Mayroon bang pagkakataon ng
pagdurugo sa may bandang gilagid po?
Endocrine
Doc: Madali po ba kayong ginawin o mainitan? Madalas po ba kayo makaramdam ng matinding pagkauhaw o
palaging nauuhaw at umiinom ng maraming tubig sa isang araw?

XI. MENTAL STATUS EXAMINATION

A. APPEARANCE AND BEHAVIOR
This section consists of a general description of how the patient looks and acts during the interview.
● Does the patient appear to be his or her stated age, younger or older?
● Is this related to the patient's style of dress, physical features, or style of interaction?
● Items to be noted include what the patient is wearing, including body jewelry, and whether it is
appropriate for the context. For example, a patient in a hospital gown would be appropriate in
the emergency room or inpatient unit but not in an outpatient clinic.
● Distinguishing features, including disfigurations, scars, and tattoos, are noted.
● Grooming and hygiene also are included in the overall appearance and can be clues to the
patient's level of functioning.
● The description of a patient's behavior includes a general statement about whether he or she is
exhibiting acute distress and then a more specific statement about the patient's approach to the
interview. The patient may be described as cooperative, agitated, disinhibited, disinterested,
and so forth. Once again, appropriateness is an important factor to consider in the interpretation
of the observation. If a patient is brought involuntarily for examination, it may be appropriate,
certainly understandable, that he or she is somewhat uncooperative, especially at the beginning
of the interview.

Doc: Sir/Mam, ask ko lang po if nitong mga nakaraan araw may mga bagay po bang nakakapag-pa
stress sainyo? If yes, pede niyo po ba ikwento sa akin if okay lang po.

B. MOTOR ACTIVITY-Pata Motor activity may be described as normal, slowed (bradykinesia), or agitated
(hyperkinesia). This can give clues to diagnoses (e.g., depression vs. mania) as well as confounding
neurological or medical issues. Gait, freedom of movement, any unusual or sustained postures, pacing,
and hand wringing are described. The presence or absence of any tics should be noted, as should be
jitteriness, tremor, apparent restlessness, lip-smacking, and tongue protrusions. These can be clues to
 adverse reactions or side effects of medications such as tardive dyskinesia, akathisia, or parkinsonian
features from antipsychotic medications or suggestion of symptoms of illnesses such as attention-
deficit/hyperactivity disorder.

Doc: Sir/Maam, pwede po ba kayong tumayo? (observe for unusual or sustained posture)
Pwede po ba kayo maglakad mula dito papunta doon (observe the gait)
Pwede po pakitaas po yung dalawang kamay nyo (observe for tremors and hand wringing)
Pwede po pakitaas at pakibaba etong ballpen/susi/cellphone?

C. SPEECH- Evaluation of speech is an important part of the MSE. Elements considered include fluency,
amount, rate, tone, and volume. Fluency can refer to whether the patient has full command of the
English language as well as potentially more subtle fluency issues such as stuttering, word finding
difficulties, or paraphasic errors. The evaluation of the amount of speech refers to whether it is normal,
increased, or decreased. Decreased amounts of speech may suggest several different things ranging
from anxiety or disinterest to thought blocking or psychosis. Increased amounts of speech often (but not
always) are suggestive of mania or hypomania. A related element is the speed or rate of speech. Is it
slowed or rapid (pressured)? Finally, speech can be evaluated for its tone and volume. Descriptive
terms for these elements include irritable, anxious, dysphoric, loud, quiet, timid, angry, or childlike.

Fluency- Observe the patient;s ability to talk spontaneously, check if he/she is stuttering
Rate- observe if he/she is talking too slow/ too fast or normal
(Repetition) Doc: Maam/Sir pwede po pakiulit etong sasabihin ko: 4986310
(Comprehension) Doc: Sir/Maam, pakipikit po yung parehong mata, pakitaas po yung kanang kamay

D. MOOD
The terms mood and affect vary in their definition, and a number of authors have recommended
combining the two elements into a new label "emotional expression." Traditionally, mood is defined as
the patient's internal and sustained emotional state. Its experience is subjective, and hence it is best to
use the patient's own words in describing his or her mood. Terms such as "sad," "angry," "guilty," or
"anxious" are common descriptions of mood.
Doc: Mam/Sir pede niyo po ba idescribe yung nafefeel o nararamdaman niyo ngayon?

E. AFFECT
Affect differs from mood in that it is the expression of mood or what the patient's mood appears to be to
the clinician. Affect is often described with the following elements: quality, quantity, range,
appropriateness, and congruence. Terms used to describe the quality (or tone) of a patient's affect
include dysphoric, happy, euthymic, irritable, angry, agitated, tearful, sobbing, and flat. Speech is often
an important clue to assessment of affect but it is not exclusive. Quantity of affect is a measure of its
intensity. Two patients both described as having depressed affect can be very different if one is
described as mildly depressed and the other as severely depressed. Range can be restricted, normal,
or labile. Flat is a term that has been used for severely restricted range of affect that is described in
some patients with schizophrenia. Appropriateness of affect refers to how the affect correlates to the
setting. A patient who is laughing at a solemn moment of a funeral service is described as having
inappropriate affect. Affect can also be congruent or incongruent with the patient's described mood or
thought content. A patient may report feeling depressed or describe a depressive theme but do so with
laughter, smiling, and no suggestion of sadness.

Affect - observe patient’s facial expressions and overall demeanor

For range, observe if throughout the interview, patient’s affect remain the same (fixed), changes slightly
(restricted), or characterized by exaggerated changes (labile)
Quantity or intensity, can be flat, heightened
Appropriateness
Congruence - affect in line with patient’s mood (congruent/incongruent)

(Observe if patient’s mood that was mentioned earlier is the same to what he/she is expressing)
Doc:
 F. THOUGHT CONTENT
Refers to what the person is actually thinking about (ideas, beliefs, preoccupations, obsessions,
phobias, recurrent ideas, hypochondriacal symptoms, specific antisocial urges). This is inferred by what
the patient spontaneous express, as well as responses to specific questions aimed at eliciting particular
pathology.
*Elicit this by asking them the things they usually think about or they can tell you these by themselves*

G. THOUGHT PROCESS
This refers to the thought processing that can described with the following terms:
● Looseness of association (irrelevance)
● Flight of ideas (changing topics)
● Racing (rapid thoughts)
● Tangential (departure from topic with no return)
● Circumstantial (being vague, i.e. beating around the bush or giving out long inordinate
responses that eventually answers the questions)
● Word salad (response makes no sense, i.e. jabberwocky)
● Derailment (extreme irrelevance)
● Neologism (creating new words)
● Clanging (rhyming words)
● Punning (talking in riddles)
● Thought blocking (speech is halted)
● Poverty (limited content)
Note if the patient answers the questions directly or deviates from the subject at hand and has to be
guided back to the topic more than once.

(Try to see if the patient answers directly or if the patient suddenly shifts to a different topic or suddenly
gets interested on bizarre things)

(Try to see if the patient’s story is chronological. The patient may also manifest jumping from one topic
to another. Notice also if the patient's story is true or if the patient seems to be only making up his/her
own story.)

(Note if the patient deviates from the question or current topic.)

(Take note if the patient can be redirected back to the subject or not at all)

H. PERCEPTUAL DISTURBANCE
● Hallucinations and illusions:
○ Patients hears voices or sees visions
○ Content, sensory system involvement circumstances of the occurrence
○ Hypnagogic or hypnopompic hallucinations
○ Thought broadcating
● Depersonalization and derealization:
○ Extreme feelings of detachment from self or from the environment

I. Cognition - (Chelsea) assess alertness, orientation, concentration, memory (short and long term),
calculation, fund of knowledge, abstract reasoning, insight and judgment
- Alertness (observe): alert, obtunded, stuporous, etc
- Orientation: What is your name or who am I? (person); What place is this or where is it located
or what city are we in? (place); What time is today or what time of day (morning, noon,
afternoon, night) or month/year? (time)
- Concentration: From 100, count backwards by 7 or 3; or say the alphabets backward starting
from letter Z, or name the months of the year backward starting from December
- Immediate memory: (same as repetition above, repeat these numbers “4986310”)
 - Recent Memory: What did you have for breakfast?
- Long term memory: Where did you live during your childhood? Or name of school teacher

● Orientation (person, place time)

Doc: Ma’am/Sir, tatanungin ko lang po ulit, ano po ang buong pangalan ninyo? (person)
Nasaan kayo ngayon/nasaang bansa? (place)
Anong petsa ngayon (buwan at taon)? (time)

● Concentration
Doc: Simula po ng December, pakisabi/enumerate po ng baliktad ang mga buwan ng isang taon.

● Memory
Doc: (Immediate) Ngayon po susuriin ko ang memorya, magsasabi po ako ng mga numero,
pagkatapos ko po sabihin ang mga ito, uulitin nyo po ito sa akin: “4-9-8-6-3-1-0”.
(Recent) Ano po ang kinain niyo kaninang umaga?/Ano po ang agahan niyo kanina?
(Long term) Saan po kayo nakatira noong bata kayo?

● Calculation
Doc: Pag meron po kayo P100 at may bibilhin kayo na P50, magkano po ang sukli na matatanggap
ninyo?

● Fund of Knowledge
Doc: Sino po ang kasalukuyang pangulo/presidente ng Pilipinas?

J. Abstract Reasoning - (MJ) ask to identify similarities between objects or concepts/interpret proverbs

Doc: Ngayon po ay susuriin po natin ang abstract reasoning niyo. Nay/ Tay maaari niyo po tukuyin kung ano
pagkakatulad o pagkakaiba sa mga bagay na babanggitin ko. Una po ay mansanas at peras (take note of
patient’s response)... pangalawa po ay bus at eroplano (take note of patient’s response). Okay, salamat po sa
pagsagot nay/tay.

K. Insight
Doc: Mr/Ms/Mrs, maari ko po ba kayong tanungin kung may idea po kayo tungkol sa (chief complaint), at kung
ano po ang naiisip at nararamdaman niyo tungkol po sa (chief complaint), at kung paano po ito nakakaapekto
sa inyong buhay sa araw-araw?

Insight refers to the patient’s understanding of how he or she is feeling, presenting, and functioning as well as
the potential causes of his/her psychiatric presentation. * Another component of insight is reality testing (just in
case may hallucinations patient) we ask about the patients insight about it. Explore patients thoughts about
his/her illness/psychosis.

L. Judgment
Doc: Meron po akong scenario na ibibigay sa inyo, Ano po ang gagawin niyo kung may makita po kayong ID
sa kalsada habang naglalakad?

*Judgement refers to the person’s capacity to make good decisions and act on them. The level of judgement
may or may not correlate to the level of insight. A patient may have no insight into his or her illness but have
good judgement. This is important to assess because this will show if the patient is capable of making
decisions for herself that would not lead her/him into trouble.
*USe real life situations from the patient’s own experience to test judgement*