877025

Mental Status Exam

Jonathan Rich, Ph.D., 04/25/08

Patient’s Name: __________________

General Appearance: ___ Gait ___ Grooming ___ Hygiene ___ Dress Older/Younger/Same as State Age

Attitude & General Behavior: ___ Pleasant ___ Cooperative ___ Oppositional

___ Perfunctory ___ Irritable ___ Tries hardest ___ Follows instructions

___ Does not initiate conversation ___ Guarded ___ Limited verbalization

___ Impulsive ___ Distractible ___Talkative ___ Agitated

Mood & Affect ___ Broad ___ Restricted ___ Blunted ___ Flat ___ Labile

___ Irritable ___ Tearful ___ Euthymic ___ Dysthymic ___ Elated ___ Anxious

Sleeping: “How would you describe your mood?” _______________________________________

Eating:

Stream of mental activity: Coherent Relevant Loose Assoc. Tangential Circumstantial

Poverty of speech Rate of speech: Slowed Normal Rapid Pressured Speech

Content: Delusions Preoccupations ___________________________________

Clear Distorted Slurred _____% intelligible

Sensorium & Orientation: Alert Aware of surroundings Confused Sedated Autistic Psychotic

Orientation: Date:_____ Day of week: _______

City of exam: _________ City of residence: _________

Memory: ___ Age ___ Birthdate ___ Current president ___ Last president

___ trials to reg. 3 objects, recall ___ out of 3 after 5 minutes

Digit span: ____ F, ____R

Fund of information: Above aver., WNL, mild/mod/sev deficient

# Legs on a dog ____ # ears _____ Where is your nose? _____

Days in wk _____ Days in yr _____ Sunrise _____ Water boil temp. _____

Concentration & Attention: Attn. to instructions: E G F P Task persistence: E G F P

Distractible Alphabet, Count 20-1: _____ secs., _____ err.

Perceptual distortions: Hallucinations: None Visual Auditory

Frequency: __________________________ Content: _______________________________

Responding to internal stimuli

Judgment & Insight: E G F P Neighbor’s house on fire: _________________

E G F P What makes it hard for you to work: ____________________

Depression: [sad/tearful] [-interest/pleasure] [sleep] [appet] [psychomotor] [fatigue] [worthless] [concentrate] [death thoughts]

Anxiety: [restless/keyed up] [fatigue] [concentration] [irritable] [tense] [sleep]

PTSD: [intrusive thts] [nightmares] [flashback] [reminders] [avoidance] [detached] [startle]

ADHD: [careless mistakes] [don’t complete] [loses things] [distracted] [disorganized]

[fidgets] [out of seat] [noisy] [talk too much] [won’t wait] [interrupts] [blurts out]

Autism: [-non-verbal] [-peer relat] [sharing interests] [lang delay][-conversation][stereotype-repet lang][lack play]

[-restricted interests][inflex routines][stereotype-repet movement][part preoccupation]

Mania: [elevated/irrit mood][grandiose][-sleep][talkative][racing thts][distractible][+activity][risky beh]

Psychosis: [delusions][hallucinations][disorg speech][disorg/catatonic beh][flat affect][avolitional]