Mental Status Examination

Name: ______________________________

Age: _____

General Appearance, Attitude and Behavior:

Attitude towards interview
_____________________________
Rapport /Attitude towards examiner
______________________________
Clothing: ______________________
Posture: _______________________
Facial expressions: _______________
Ease in separation with caregiver
Attention span
Motor activities
o Orderly, Calm, Agitated
o Restless, Tics, Mannerisms
o Ataxia, Akathisia
Gross Motor Activity:_____________
Fine Motor Activity:______________
Hyperactive, Hypoactive

Preoccupations and exaggerated concerns

Obsessions:
___________________________
Compulsions:
___________________________
Phobias:
___________________________
Hypochondrical ideas:
___________________________

Speech and Language:

Neologisms:_____________________
Talkative, Mute, Mumbled
Response Speed
o Slow, Rapid, Normal
Fluency
o Slurred, Stuttering, Fluent
Loudness
o Loud, Whispered, Normal
Spontaneity
Repetitions
Content of Thought:
Selective attention
Theme/ Subject area of focus
__________________________________

Date: _______________

Distortions of Reality
Hallucinations
Auditory: _____________________________
Visual: _______________________________
Gustatory: ____________________________
Olfactory: _____________________________
Tactile: _______________________________
Kinesthetic: ____________________________
Imaginary companions: ___________________
Delusions
______________________________________
Sensorium
Orientation to
Place:___________________________
Date:___________________________
Time:___________________________
Situation:________________________
Memory
Remote: _________________________
Recent: __________________________