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Mental State Exam - form

Academic year: 2018/2019
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Technische Universiteit Delft

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Mental Status Examination Rapid Record Form

Number

© 2000 Jeff Patrick. Those studying, researching or practicing psychology or psychiatry, and those organizations that support them may freely duplicate, modify, distribute, and use this form.

Name

Date of birth

Gender M F

Circumstance of presentation

5 Tick where appropriate General Description

Appearance Weight ‡ Obese ‡ Over-weight ‡ Under-weight ‡ Emaciated Hair ‡ Bizarre style ‡ Unnatural color ‡ Unshaven Other Features ‡ Wounds ‡ Scars ‡ Tattoos ‡ Jewelry ‡ Glasses ‡ Dental braces Grooming ‡ Disheveled ‡ Soiled ‡ Body odor ‡ Halitosis Dress ‡ Undressed ‡ Underdressed ‡ Overdressed ‡ Bizarre ‡ Militaristic

Behavior Walk ‡ Gait/march ‡ Limp ‡ Shuffle ‡ Assisted Combativeness ‡ Cataplexy ‡ Aggressive Repetition ‡ Gestures ‡ Twitches ‡ Stereotypical ‡ Automatism ‡ Mimicry ‡ Echopraxia Overactivity ‡ Psychomotor Agitation ‡ Hyperactivity ‡ Tic ‡ Sleepwalking ‡ Compulsion

Catatonia ‡ Catalepsy ‡ Exited ‡ Stupor ‡ Rigidity ‡ Posturing ‡ Cerea Flexibilitas ‡ Negativism Speech Speech Rate ‡ Rapid ‡ Slow Intelligibility ‡ Slurred ‡ Mumbled ‡ Stutters ‡ Accented Volume ‡ Loud ‡ Whispered Speech Quality ‡ Hesitant ‡ Emotional ‡ Monotonous ‡ Stereotypical ‡ Unspontaneous ‡ Echolalia ‡ Verbigerative Speech Quantity ‡ Garrulous ‡ Talkative ‡ Responsive ‡ Taciturn ‡ Mutism Attitude to Examiner ‡ Seductive ‡ Playful ‡ Ingratiating ‡ Friendly ‡ Cooperative ‡ Interested ‡ Attentive ‡ Frank ‡ Indifferent ‡ Evasive ‡ Defensive ‡ Hostile

Mood and Affect Mood ‡ Ecstatic ‡ Euphoric ‡ Expansive ‡ Elevated ‡ Euthymic ‡ Dysphoric ‡ Anhedonic ‡ Depressed ‡ Alexithymic ‡ Grieving Other Emotions ‡ Panicked ‡ Fearful ‡ Anxious ‡ Tense ‡ Agitated ‡ Apathetic ‡ Irritable ‡ Angry Other Signs ‡ Ambivalence ‡ Mood Swings Neuro-Vegetative ‡ Anorexia ‡ Insomnia ‡ Hypersomnia ‡ Diminished Libido ‡ Constipation Affective Expression ‡ Normal ‡ Restricted ‡ Blunted ‡ Flat Appropriateness ‡ Appropriate ‡ Inappropriate ‡ Labile

Perception Hallucinations ‡ Hypnagogic ‡ Hypnopompic ‡ Auditory ‡ Visual ‡ Olfactory ‡ Gustatory ‡ Tactile ‡ Somatic ‡ Lilliputian ‡ Mood-congruent ‡ Mood-incongruent ‡ Hallucinosis ‡ Synesthesia ‡ Trailing Disassociation ‡ Hysterical anesthesia ‡ Macropsia ‡ Micropsia ‡ Depersonalization ‡ Derealization ‡ Fugue ‡ Multiple personality Agnosia ‡ Anosognosia ‡ Autotopagnosia ‡ Visual agnosia ‡ Astereognosia ‡ Prosopagnosia

Current Treatment ‡ Current psychotherapy

‡ Current psychoactive medication

Risk Asse ssm e nt

5 Tick where appropriate

Thought Process

Content of Thought ‡ Poverty of thought ‡ Overvalued idea ‡ Trend of thought ‡ Egomania ‡ Monomania ‡ Hypochondria ‡ Obsession ‡ Compulsion ‡ Noesis ‡ Unio mystica ‡ Delusions ‡ Bizarre ‡ Systematized ‡ Mood-congruent ‡ Mood-incongruent ‡ Nihilistic ‡ Somatic ‡ Paranoid ‡ Persecutory ‡ Grandeur ‡ Referential ‡ Self-accusatory ‡ Control ‡ Thought withdrawal ‡ Thought insertion ‡ Thought broadcasting ‡ Infidelity ‡ Erotomania ‡ Pseudologia fantas- tica

‡ Preoccupations Suicidal Ideation ‡ Ideation history ‡ Previous attempt/s ‡ Current ideation ‡ Impulsiveness ‡ Viable plan ‡ Available means ‡ Settling of affairs Hostile Intent ‡ Previous intimidation ‡ History of violence ‡ Current intent ‡ Impulsiveness ‡ Viable plan ‡ Available means

‡ Phobia ‡ Simple ‡ Social ‡ Acrophobia ‡ Agoraphobia ‡ Claustrophobia ‡ Xenophobia ‡ Zoophobia Thought Form General ‡ Mental disorder ‡ Neurosis ‡ Psychosis ‡ Reality testing ‡ Formal thought dis. ‡ Illogical thinking ‡ Dereism ‡ Autistic thinking ‡ Magical thinking ‡ Concrete thinking ‡ Abstract thinking Specific ‡ Neologism ‡ Word salad ‡ Circumstantiality ‡ Tangentiality ‡ Incoherence ‡ Perseveration ‡ Condensation ‡ Irrelevant answers ‡ Loosening ‡ Derailment ‡ Flight of ideas ‡ Clang association ‡ Blocking ‡ Glossolalia Disturbances of speech ‡ Pressured ‡ Voluble ‡ Poverty of Speech ‡ Poverty of Content ‡ Dysprosody ‡ Dysarthria Aphasic Disturbances ‡ Motor ‡ Sensory ‡ Syntactical ‡ Jargon ‡ Global

Sensorium & Cognition Consciousness ‡ Disoriented ‡ Clouding ‡ Stupor ‡ Delirium ‡ Coma ‡ Coma vigil ‡ Twilight state ‡ Dreamlike state ‡ Somnolence Orientation ‡ Time Disorientation ‡ Place Disorientation ‡ Person Disorientation Concentration ‡ Serial 7’s inattention ‡ Easily distracted ‡ Often distracted Memory ‡ Remote memory deficit ‡ Recent past deficit ‡ Recent memory deficit ‡ Immediate recall deficit Information & Intelli- gence Attention ‡ Distractible ‡ Selective attention Suggestibility ‡ Folie à deux ‡ Hypnotized Memory ‡ Localized amnesia ‡ Generalized amnesia ‡ Selective amnesia ‡ Continuous amnesia ‡ Paramnesia ‡ Fausse reconnaissance ‡ Retro. falsification ‡ Confabulation ‡ Déjà entendu ‡ Déjà pensé ‡ Déjà vu ‡ Jamais vu ‡ Hypermnesia ‡ Eidetic images

Intelligence ‡ Mild retardation ‡ Moderate retardation ‡ Severe retardation ‡ Profound retardation ‡ Dementia ‡ Pseudodementia Judgment ‡ Critical ‡ Automatic ‡ Impaired Insight ‡ Impaired insight ‡ Denial of disorder ‡ External locus of disor- der ‡ Intellectual insight ‡ True insight Reliability ‡ Reason to fake bad ‡ Reason to fake good ‡ Compulsory examina- tion Summary Global Functioning ‡ 10 Imminent harm ‡ 20 Possible harm ‡ 30 Serious Impairment ‡ 40 Major Impairment ‡ 50 Serious Symptoms ‡ 60 Moderate Symptoms ‡ 70 Mild Symptoms ‡ 80 Slight Impairment ‡ 90 No Symptoms ‡ 100 Superior Function

Indications & Recommendations

________________________________________

Signature of Examiner Date © 2000 Jeff Patrick. Those studying, researching or practicing psychology or psychiatry, and those organizations that support them may freely duplicate, modify, distribute, and use this form.

WARNING

The contents of this document are strictly confidential. It or any part of it may not be pos- sessed, duplicated or used in any way without the consent of both the owner and the person to which it pertains.

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Mental State Exam - form

Course: Counselling Psychology (PSY3050)

University: University of Southern Queensland

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Mental Status Examination Rapid Record Form
Number
© 2000 Jeff Patrick. Those studying, researching or practicing psychology or psychiatry, and those organizations that support them may freely duplicate, modify, distribute, and use this form.
Name
Date of birth
Gender M F
Circumstance of presentation
5 Tick where appropriate
General Description
Appearance
Weight
Obese
Over-weight
Under-weight
Emaciated
Hair
Bizarre style
Unnatural color
Unshaven
Other Features
Wounds
Scars
Tattoos
Jewelry
Glasses
Dental braces
Grooming
Disheveled
Soiled
Body odor
Halitosis
Dress
Undressed
Underdressed
Overdressed
Bizarre
Militaristic
Behavior
Walk
Gait/march
Limp
Shuffle
Assisted
Combativeness
Cataplexy
Aggressive
Repetition
Gestures
Twitches
Stereotypical
Automatism
Mimicry
Echopraxia
Overactivity
Psychomotor Agitation
Hyperactivity
Tic
Sleepwalking
Compulsion
Catatonia
Catalepsy
Exited
Stupor
Rigidity
Posturing
Cerea Flexibilitas
Negativism
Speech
Speech Rate
Rapid
Slow
Intelligibility
Slurred
Mumbled
Stutters
Accented
Volume
Loud
Whispered
Speech Quality
Hesitant
Emotional
Monotonous
Stereotypical
Unspontaneous
Echolalia
Verbigerative
Speech Quantity
Garrulous
Talkative
Responsive
Taciturn
Mutism
Attitude to Examiner
Seductive
Playful
Ingratiating
Friendly
Cooperative
Interested
Attentive
Frank
Indifferent
Evasive
Defensive
Hostile
Mood and Affect
Mood
Ecstatic
Euphoric
Expansive
Elevated
Euthymic
Dysphoric
Anhedonic
Depressed
Alexithymic
Grieving
Other Emotions
Panicked
Fearful
Anxious
Tense
Agitated
Apathetic
Irritable
Angry
Other Signs
Ambivalence
Mood Swings
Neuro-Vegetative
Anorexia
Insomnia
Hypersomnia
Diminished Libido
Constipation
Affective Expression
Normal
Restricted
Blunted
Flat
Appropriateness
Appropriate
Inappropriate
Labile
Perception
Hallucinations
Hypnagogic
Hypnopompic
Auditory
Visual
Olfactory
Gustatory
Tactile
Somatic
Lilliputian
Mood-congruent
Mood-incongruent
Hallucinosis
Synesthesia
Trailing
Disassociation
Hysterical anesthesia
Macropsia
Micropsia
Depersonalization
Derealization
Fugue
Multiple personality
Agnosia
Anosognosia
Autotopagnosia
Visual agnosia
Astereognosia
Prosopagnosia
Current Treatment
Current psychotherapy
Current psychoactive medication

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