mental status examination template
DESCRIPTION
Mental Status Examination TemplateTRANSCRIPT
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