Mental Status Examination upon Initial Introduction and Succeeding Visits

PSYCHIATRIC HISTORY AND ASSESSMENT TOOL

Identifying/Demographic Information
Room No.

Name:
Primary Care Provider:
DOB:
Age:
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:

Sex:

NAME

Family Members/Significant Others Living In Home

RELATIONSH AGE
OCCUPATION/GRADE
IP

NAME

Family Members/Significant Others Not In Home

RELATIONSH AGE
OCCUPATION/GRADE
IP

Temp:
Height:

Pulse:
Weight:

MEDICAL HISTORY
RR:

BP:

Cardiovascular (CV) Does client have or ever had the following disorders/symptoms?
Include date

Hypertensions:
Murmurs:
Chest Pain (Angina):
Children
Palpitations/Tachycardia: Shortness of
Breath:
Ankle Edema/ CHF:
NAME
AGE
LIVING
ATCholesterol:
HOME?
Fainting/Syncope:
Myocardial Infarction:
High
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:
Past
Psychiatric
Treatment/Medications
Dizziness/Vertigo:
Loss of Consciousness:
Stroke:
It is important
to obtain a history
of anyDisease:
previous psychiatric
hospitalizations, the
Myasthenia
Gravis:
Parkinsons
Dementia:
number
of hospitalizations Seizure
and dates,
and to record all current/past
psychotropic
Brain
Tumor:
Disorder:
Multiple Sclerosis:
medications
as
well
as
other
medications
the
client
may
be
taking.
Ask
the client
TIAs:
Other:
Surgeries:
what has worked in the past,
and also
hashad
notthe
worked
for disorders/symptoms?
both treatment and
Dertmatological/Skin
Does client
havewhat
or ever
following
Include
date
medications.
Treatment Itching:
Psoriasis:
HairInpatient
Loss:
Facility/Locatio
Dates
From/To
Diagnosis
Treatments
Response (s)
Rashes:
Acne:
Other/Surgeries:
n
Endocrinology/
Metabolic Does client have or ever had the following
disorders/symptoms? Include date

Polydipsia:
Polyuria:
Diabetes Type 1 or 2:
Outpatient
Treatment/Services
Hyperthyroidism:
Hypothyroidism:
Hirsutism:
Psychiatrist
Location Other: Diagnosis
Treatment
Response (s)
PCOs:
Surgeries:
Eyes, Ears, Nose Throat
Eye Pain:
Halo around Light Source: Blurring:
Red Eye:
Double Vision:
Flashing Lights/Floaters:
Psychotropic
Medications
(Previous
Treatments)
Glaucoma:
Tinnitus:
Ear
Pain/Otitis Media:
Name
Dose/Dosages
Response
Comments
Hoarseness:
Other: Treatment
Other Surgeries:
Gastrointestinal
Length
Nausea and Vomiting:
Diarrhea:
Constipation:
GERD:;
Crohns Disease:
Colitis:
Colon Cancer:
Irritable Bowel Syndrome: Other/Surgeries:
Genito-urinary/Reproductive
Miscarriages Current
Y/N:
Abortions? Y/N: Medications
Psychotropic Medications/Other
Current
Psychotropic
Medications
# and when?
# and when?
Name Discharge:Dose/Dosages
Date
Started
(s)
Serum Levels
Nipple
Amenorrhea:
Gynecomastia:
Family History Response
Lactation:
Dysuria:
Urinary
Incontinence:
Mental Illness: Schizophrenia, Paranoid (Paternal side)
Pregnancy
Problems:
Postpartum Depression:
Sexual Dysfunction:
Medical
Disorders:
Prostate
Problems:
Menopause:
Fibrocystic Disease:
Substance Abuse (please note who in the family has a problem/disorder):
Other Current
Medications/Herbals/and
OTC medications
Penile
Discharge:
UTI: Substance
Pelvic Pain:
Abuse
Name
Dose/Dosages
Date
Started
Response
Renal Disease:
Urinary Cancer:
Breast (s)
Cancer:Serum Levels
Prescribed
Drugs
Other/Surgeries
Other
Gynecologic Cancer Other:
Name
Dosage
Reason
Respiratory
Chronic Cough:
Sore Throat:
Bronchitis:
Asthma:
COPD:
Pneumonia:
Cancer
(Lung/Throat):
Street Drugs
Sleep Apnea:
Other/ Surgeries
NONE
Name
Amount/Day
Reason
Other Questions
Allergies (food/environment/pet/contact):
Diet:
Drug Allergies:
Alcohol
Accidents:
Name
Amount/Day
Reason
High Prologed Fever:
Childhood Illness:
Fractures:

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:
ATTITUDE
APPEARANCE
Is
client:
(Check
if
Present)
Day32
Day
3 4Day 4 Day
Day
Describe
Day 1
Day Day
2 1 Day
Day
55
Cooperative
Grooming/Dress
Uncooperative
Hygiene
Warm/Friendly
Eye
Contact
Distant
Posture
Suspicious features
Identifying
Combative
(Marks/scars/Tattoo
Guarded
s)
Aggressive versus
Appearance
Hostile
stated age
Aloof
Over all
Apathetic
Appearance
Other specify:
Check if present

BEHAVIOR/ACTIVITY
MOOD AND AFFECT
Day 1 Day 2
Day 1
Day 2

Is client: (Check if Present)

Hyperactive
Elated
Agitated
Sad
Psychomotor retardation
Depressed
Calm
Irritable
Tremors
Anxious
Unusual movements/gestures
Fearful
Catatonia
Guilty
Akathisia
Worried
Rigidity
Angry Movements(jaw/lip smacking)
Facial
Hopeless
Others:
(Specify)
Labile
Mixed (Anxious and Depressed)
SPEECH
Is clients Affect:
Describe
Day 1
Day 2
Flat
Slow/Rapid:
Blunt or Diminished
Pressured:
Appropriate
Tone:
Inappropriate/Incongruent
Volume
(loud/soft)
Other Specifiy:
Fluency
(mute/hesitation/lat
ency of response):
(Check if Present)
Other specify:
Concrete Thinking
Circumstantiality
Tangentiality

Day 3

THOUGHT PROCESS
Day 1
Day 2

Day 3
Day 3

Day 4
Day 4

Day 4

Day 3

Day 4

Day 5
Day 5

Day 5

Day 5

Loose Association
Echolalia
Flight of Ideas
Perseveration
Clang association
Blocking
Word Salad
Derailment
Others Specify:
THOUGHT CONTENT
Does Client have: (Check if Present)
Day 1
Day 2
Delusions:
a. Grandiose
b. Persecutory
c. Reference
d. Somatic
Suicidal Thoughts
Homicidal Thoughts

Day 3

Day 4

Day 5

PERCEPTUAL DISTURBANCES
Day 1
Day 2
Day 3

Day 4

Day 5

Day 4

Day 5

If homicidal, towards whom?

Obsessions
Paranoia
Phobias
Magical Thinking
Poverty of Speech
Others Specify:

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 1
Day 2
Orientation (Yes/No)

Day 3

a. Time
b. Place
c. Person
Memory (Good/Poor)
a. Recent
b. Remote
c. Confabulation (Y/N)
Level of Alertness
INSIGHT and JUDGEMENT
Day 1
Day 2
Insight (Awareness of the nature of
the Illness)
Judgement (Good/Poor)
Impulse Control (Good/Poor)
Concentration (Good/Poor)
Attention (Good/Poor)
Other Specify:

Day 3

Day 4

Day 5

A.

Mental Status Exam

Day 1

Day 2

Day3

Day 4

Day 5

A. General
appearance
B. Posture
C. Behaviors
D. Distant

A.1 Speech
Day 1
Soft
Loud
Hesitant
Slurred
Superior
Humor
Frightened

Day 2

Day 3

Day 4

Day 5

A.2 Does his style and vocabulary covey?

Day 1

Day 2

Day 3

Day 4

Day 5

Coyness
Suspiciousnes
s
Arrogance
Secrecy
Superiority
Humor
Fear

A.3 Stream of talk

Day 1

Day 2

Day 3

Day 4

Day 5

Day 2

Day 3

Day 4

Day 5

Spontaneous
Deliberate
Pressured

A.3 Organization of Talk

Day 1
Relevant
Irrelevant

Incoherent
Loose Associat
ion
Flight of Ideas
Tangentiality
Circumstantialit
y
Perseveration
Clang
Association
Neologism
Echolalia
Echopraxia

A.5 Mood and Affect

Day 1
1. Mood
Euthymic
Depressed
Euphoric
2. Affect
Flat
Blunt
Angry
Elated
Anxious

Day 2

Day 3

Day 4

Day 5

Fearful

A.6 Range of Affective Expressions

Day 1

Day 2

Day 3

Day 4

Day 5

Consistent
Labile
Anhedonic
Appropriate
to

the

situation and
feelings
verbalized

A.7 Perception
Day 1
Hallucination

Auditory

Visual

Olfactory

Tactile

Delusion
Grandeur
Persecutory
Reference
others
Illusion

Day 2

Day 3

Day 4

Day 5

Derealization
Identification
Thought
broadcasting
Deje Vu
Jamis Vu

A.8 Organization and Memory

D1

D2

D3

D4

D5

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 Functioning

D1
Sleep and Rest Pattern

Normal sleep

Early morning awakening

Middle night awakening

Hyper insomnia

Difficulty of falling asleep

D2

D3

D4

D5

Interrupted sleep

A.10 Elimination
Day 1

Day 2

Day 3

Day 4

Day 5

Day 1

Day 2

Day 3

Day 4

Day 5

Day 1

Day 2

Day 3

Day 4

Day 5

Bowel
Bladder

A.11 Abstract Thinking Ability

Abstract
thinking
ability

A.12 Judgment

Judgment