Mental Status Exam Recording Sheet - PsychPage

1 Mental Status Exam FormClientDateEthnicityApparent Ageyoungerstated ageolderHandednessRightLeftSexmalefemale Buildaverageunderweighthealthythinpetite stockyStaturebelow averageaverageabove averageCoordination and Gaitno difficultiessome anxiousness and restlessnesssome clumsinessused a caneawkwardstaggeredshufflingGroominggoo dneglectedpoorsatisfactoryadequateDressc asualok for workok for agestylishok for weatherdirtyInterpersonal Style congenialguardedopen/candidpatient/coope rativefriendly/politequiet/withdrawndist ant/disengagedannoyed/irritableengagingh ostilesomewhat shyopen and motivatedrelaxed/unconcernedcautious/def ensiveirritable/guardedRepeated QuestioningyesnoApproachcooperativeconsc ientiousunconcernedpassive/unassertivene gativistic/criticalhurriedlethargicuncer tain/somewhat anxious/declined to guesscompliant but poorly motivateddependentmotivated/focusedapath etic/carelessresistant and defensivecareless and sloppyneeded minor/considerable reinforcement and soothinginterested/thoughtfulSpeechunder standable/clearcoherent/meaningfulnormal rate/volumeappeared thoughtfulabundant/excessiveoverly friendlysimple/soft-spokenstutteringincl uded profanitycritical/sarcasticcatch phrases and clichesimpoverished w/ little detailfluent/easy to understandclear/logicalvariable rate but clearused a loud voiceanimated/confidentmumbleddifficulty

2 Finding wordspoor articulationpressured/fast-pacedslurred/ hard to understandEye Contactgoodfleetingbrief contact quickly brokennormalavoidedConversationcould initiate and holdunwilling to engagehesitantuse of odd or bizarre wordsno difficultiesdifficulty finding wordsunable/able to comprehend questionsnote if English is not primary language, comment on command Recall of Personal Hxno difficultysome difficultyhonestlysome reluctanceRecent Pastadequate detailsparse detailnormal level of detailavoided certain topicsRecall Of 3 Words(like Cadillac, Purple, and Zebra)3210 Prompting HelpedyesnoExaminer's NamerememberedforgotCertainty of Informationprobably trueveracity is doubtfulAlert/Orientedalert and orienteddistractedno distractibilityhigh distractiblebasically orientedno impairmentimperfecttired/from working late Communicationscoherentclear/understandab lelacking in needed detailconfusingreluctant and hesitantoverly detailed and difficult to followRelevanceclear and appropriateon-topicirrelevant/inappropri ateoff-topicrelevanttangential/unrelated Thought Processesorganizedconcrete/simplisticstr ained/illogicalclear/understandableno loose associationspreoccupationsperseverativep oorly organized/difficult to follow most of timesome disorganized

3 Reasoningconfusing/difficult to followsuspiciousness or paranoid reasoningno pressured speech or obsessive thoughtsno difficulty explaining thoughts and finding wordsno indications of a formal thought disorderHallucination and Delusionsno historysome historyno history except associated with drugsno history, but some evidenceAttention and Concentration(Serial 3s or 7s, "WORLD", days or months backwards)satisfactoryadequate or sufficientvariable, likely due to apparent depressionno sig impairmentmildly deficientpoordistractibleadequateadequat e, with occasional distractionsmild to mod impairmentMotivationpoor motivationinconsistentdid not improveeasily weakenedsample proverbsA rolling stone gathers no mossIn the land of the blind, the one-eyed person is kingAll that glitters is not goldDon't count your chicken before they hatchDon't put all your eggs in one basketStrike while the iron is hotRome wasn't built in a dayWhen the cat's away the mice will playA stitch in time saves nineYou can dress a monkey in silk but it's still a monkey ("Aunque la mona se vista in ")

4 Sample sayingsWhat would I mean if I said I were feeling blue? seeing red? I had a chip on my shoulder? or was hot under the collar?sample duplicate definitionsleft, bit, right Judgment and Intellectual Ability good, able to anticipate outcomesadequate, able to use feedback to learn from mistakesfair, able to learn from some experiencespoor, difficulty predicting results of choicesroughly average, above average, or below averagebased on ?s like "name last four presidents," "who is the governor of the state," "what is the capitol of the state," "what direction does the sun set" ..Abstractionpoor, adequate, good, based on proverbs and sayings, similarities, and duplicate definitions for wordsMemoryreported problemscould/could not recall plot of favorite movie or book logicallydenied problemsdifficult to understand line of reasoningMood and Affect (Climate and Weather)

5 Calm and composedreservedseemed depressedirritatedsomewhat agitatedanxiousbored and disinterestedupbeat and elevatedgenerally relaxed/untroubledinitially calm, but subduedlabileconsistently happyconsistent w/ reported moodApparent Emotionsannoyedcalmresentfulanxiousagita teddefeatedshamefuldefendedunfairly treatedFacial and Emotional Expressionsrelaxedtensesmiledlaughedbeca me insultingyelledhappysadalertday-dreamyan grysmilingdistrustful/suspicioustearful when discussing such and suchDisplays of Inappropriate AffectyesnoSuicidal/Homicidal Thoughtsdenieddenied, but To Failuresunconcerned byunaware ofdemoralized byable to recover afterfrustrated oversatisfied to acceptannoyed bydistressed byunmotivated to improve afterResponse To Rapporteasyeasy after anxiety decreasedtenuousdifficulteasy then difficulteasily upsetAudio Commentaudio-taped administrationdepressed and poor concentrationpoor comprehensionpoor motivationskipped some questionnairesquestions read by examiner; answers taken by dictationForm by Richard Niolon.