Appearance

Male/Female
Ethnicity:
Chronological Age:
Apparent Age:
Affect:
Eye Conctact
Dysthymic Euthymic Dysphoric Euphoric
Makes
Avoids
Hesitant to make eye conctact
Gait and Motor Coordination (circle all that apply):
Full range Blunted
Flat
Labile
Awkward Staggering Shuffling Rigid
Trembling w/ intentional movement or rest
Mood
Psychomotor agitation
Psychomotor retardation
Happy
Sad
Ok
Afraid
Angry
Anxious
Speech
Normal rate and volume
Pressured Impoverished
Intensity:
Logorrhea Fluent
A little
A lot
In between
Slurred
Echolalia Articulate Word Salad
Anomia
Can understand questions?
Yes
No
Congruent to affect?
Yes
No
Can name common objects?
Yes
No
Appropriate to context?
Yes
No
Can place right hand on left ear? Yes
No
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Thought
Logical
Yes
No
Thought broadcasting Yes
No
Sequential
Yes
No
Thought withdrawal
Yes
No
Goal-directed
Yes
No
Thought insersion
Yes
No
Loose associations
Yes
No
Blocking
Yes
No
Confabulations
Yes
No
Circumstantial speech Yes
No
Flight of ideas
Yes
No
Tangential speech
Yes
No
Magical thinking
Yes
No
Suicidal and Homocidal Thoughts
Ideation but no plan or intent

Clear/Unclear plan but no intent

Clear plan and intent

Preoccupations?
Perception
Has your mind been playing tricks on you? Y N
Do familiar things seem fake or new?
Y N
Feel outside and looking in on yourself?
Y N
Does the TV/radio ever speak only/specifically to you?
Y N
How often experience hallucination?
Sensorium
Alertness
Alert
Orientation
Person
Place

Drowsy
Time

Lethargic

Stupor

Coma

Y N
Y N
Y N
Y N

Immediately after rehearsals

Again five minutes later
*If NO, you can prompt them*

Digit span forward:

Digit span backward:
Recalls current general events?
Recalls remote general events?

Situation

Concentration and Attention

Count backwards from 100 by 7's
Count backwards from 20 by 3s
Name the months of the year in reverse
Spelling the word "WORLD", their last name backwards
Memory
Recalls three words:

Heard voices or noises when no one was around? Y

Have you seen things others dont?
Y N
Recognize hallucinations as unreal?
Y N

Yes
Yes

Y N
Y N
Y N

No
No

Abstract Reasoning
"Dont cry over spilled milk"
"You cant judge a book by its cover"
"A rolling stone gathers no moss"

Concrete
Concrete
Concrete

Abstract
Abstract
Abstract

Typical
Typical
Typical

Judgement
What would you do if you saw smoke in a theater?
What would you do if you saw a stamped letter on the ground near a mail box?
Reading and Writing
Can write their name
Can write dictated sentence
Can read sentence aloud
Read instructions silently and follow

Yes
Yes
Yes
Yes

No
No
No
No

Visuospatial Ability
Can copy figure

Yes

No

Impulsivity
Observations:
Reliability

Open and spontaneous or guarded and secretive?

Does history cohere into narrative whole?
Yes
Is patients story contradictory?
Yes
Cognitive/attentional impairment?
Yes

No
No
No