Date of birth
Gender MF
Tick where appropriate
General Description
Appearance
Weight
D Obese
D Over-weight
D Underweight
D Emaciated
air
OBizarre-style
1D Unnatural color
OUnshaven
Other Features
D Wounds
D Scars
1 Tattoos
D Jewelry
OGlasses
D Dental braces
Grooming
D Disheveled
O Soiled
D Body odor
D Halitosis
Dress
Undressed
D Underdressed
1D Overdressed
OBizarre
DGaivmarch
DLimp
O Shute
Dassisted
Combativeness
DO Cataplexy
DaAgagressive
Repetition
D Gestures
D Twitehes
D Sterectypical
1D Automatism
DMimicry
DEchopraxia
Overactivity
1D Psychomotor Agitation
D Hyperactivity
OTic
D Sleepwalking
Circumstance of presentation
Catatoni [Mood and Affect roeption
Dena Mood Hallucinations
D Star D Ecstatic 1D Hypnagogic
Row D Euphoric 1 Hypnopompic
Breen Expat 1D Auditory
Ol Elevated D Visual
U Cerea Fiexibiltas Di Euthymic D Olfactory
1G Negativism 1D Dysphoric O Gustatory
Speech Dl Anhedonic O Tactile
‘Speech Rate Oi Depressed 1 Somatic
D Rapid D Alexithymic O Liliputian
DSiow O Grieving 1 Mood-congruent
intelligibility Qther Emotions O Mood-incengruent
DSlurred 0 Ponicked 1D Hallucinosis
OMumbied O Fearul 1 Synesthesia
1D Stutters D Anxious Di Trailing
D Accented O Tense Disassociation
Volume D Agitated “Hi Hysterical anesthesia
DLoud D Apathetic DB Macropsia
D Whispered D Irritable O Micropsia
Speech Quality DAnary 0 Depersonatization
DHesitant Other Signs 1 Derealization
D Emotional 1 Ambivalence DFugue
CD Monotonous C1 Mood Swings 1 Multiple personaly
D Stereotypical Neuro-Vegetative r
1D Unspontaneous D Anorexia anes
D Echolalia D Insomnia Tr Anosognasis
1D Verbigerative Oi Hypersomnia O Aattopsanosie
Speech Quantity Oi Diminished Libido sual agnosia
1D Garutous Constipation £ ppeeeanrs
D Talkative ‘Affective Expression rosopagnosia
O Responsive Tl Normal
OC tectum D Restricted
en - Oi Blunted
Altitude to Examiner | OFiat
D Seductive [Appropriateness
OPaya 1 Appropriate
1D ingratiating Di Inappropriate
O Friendly ae
D Cooperative
Daten? | Current Treatment
ER Current psychotherapy
D inditferent
D Evasive
B peters | 1 Current psychoactive medication
1B CompulsionBZ Tick where.
[Thought Process.
‘Content of Thought
y
1D Overvalued idea
1D Trend of thought
(D Egomania
‘O Monomania
(D Hypochonaria
D Obsession
(OD Compulsion
DNoesis
[D.Unio mystica
1D Delusions
O Bizarre
1D Systematized
1D Moad-congruent
D Mood-incongruent
CO Nibilistic:
1D Somatic
1D Paranoid
1D Persecutory
0 Grandeur
O Referential
1 Self-accusatory
O Control
CD Thought withdrawal
D Thought insertion
1D Thought broadcasting
1D Infidelity
1D Erotomania
1D Pseudologia fantas-
tica
1D Preoccupations
Suicicfal ideation
DD ideation history
1 Previous attempts
1D Current ideation
Di impulsiveness
1D Viable pian
D Available means
1D Settling of affairs
Hostile intent
1D Previous intimidation
D History of violence:
1D Current intent
1 impulsiveness
1D Viable pian
D Available means
D Phobia
Simple
D Social
O Acrophobia
Agoraphobia
O Claustrophobia
1D Xenophobia
1D Zoophobia
Thought Form.
General
O Mental disorder
OD Neurosis
1 Psychosis,
GD Reality testing
1D Formal thought dis.
1D logical thinking
1 Dereism
Autistic thinking
1D Magical thinking
1D Conerate thinking
D Abstract thinking
Specific
D Neologism
1D Word salad
1D Circumstantiatity
O Tangentiality
1D Incoherence
O Perseveration
O Condensation
D Irrelevant answers
1D Loosening
OD Deraiiment
1 Flight of ideas
1D Clang association
Blocking
O Glossolalia
Disturbances of speech
Pressured
1D Volubie
O Poverty of Speech
1 Poverty of Content
1 Dysprosody
1 Dysarthria
Aphasic Disturbances
O Motor
O Sensory
1 Syntactical
D Jargon
Global
Indications & Recommendations.
1D Moderate retardation
Severe retardation
G Profound retardation
Dementia
[Sensorium & Cognition | Intelligence
Consciousness 1 Mild retardation
pense
oo 1 Pseudodementia
Coma vigil Jud
O Twilight state O Critical
O Dreamilike state o Automatic
1D Somnolence Dip:
Insight
O Impaired insight
Place Disorientation Gl Denial of disorder
D Person Disorientation _ 1 Extemal locus of disor-
pancerteation Tinetetual insight
ual insi
D Serials inattention rue insight
O Easily distracted
GOrendsacies __[Retabili =
Mamory. feason to fake bad
Taq” Oi Reason to fake good
Dee oer tetet El Compulsory examina-
DRecent memory deficit Hot.
Ci immediate recall deficit [Summary
i - Global Functioning
inforrmesion | ntemt: 0.10 Imminent harm:
ae 101.20 Possible harm
Neer 15 30 Serious Impairment
5 1.40 Major Impairment
1 Selective attention pe
Suggestibility 050 Serious Symptoms
Sugge 160 Moderate Symptoms
‘olie 4 deux
D Hypnotized O70 Mild ‘Symptoms
80 Slight Impairment
Memory
1.90 No Symptoms
Di Localized smmnesie 1D 100 Superior Function
O Generalized amnesia
O Selective amnesia
OD Continuous amnesia
O Paramnesia
O Fausse reconnaissance a ee oe
O Retro. fatsification 1@ cont u
O Confabulation document are strictly
O Deja pensé a
Ogawa sessed, [or
1D Jamais vu used in any way witfrout
CO Hypermnesia the consent of bath the
1 Eidetic images eee to.
Signature of Examiner
"Saunt set Fatih Those shen tescuchna ot Bsiora paTORY oT GURY ahd Pose aTaatara PN pESH eT way NeOy Spe MOST, Gate anise PsSelected glossary
‘Abret thinking. Tinkng characorsad anos exc
‘ily by cate atatacios, aber han nmodate
sensnyepernce
Aerophotla Fos alba
‘Ait Th pani lesan aavoue wtih
‘epresson ofa sutjacteyerpeencad fag
{emoton) and i varable over te in response t>
change onctonal sites,
Agwapobia A lie of beg in pla oe atone
Tahoh ecape mag be eect er embarassing of 6
‘Mien hep ay Nate atable shou a pric aac.
‘Abtry, Reavy uniter ents unable
Teeny or express anton), ad Biking ends
‘uel excensny 09 the mundane, Ores, ard
tray eet docal,
‘Aatedonic. A inci 10 ery aning even Binge
siosbie
Blockog, Repealed and steph i a SR 0 8
ollaang es an ol eg
CCaalepay A vanclne sas wet oss of ottary moon
‘ad tao eat stra
Cataplry. Sete, avai decrement h ma oe &
os of Gap reese hl eats fusca wea,
paras, poste cole. Ususiy caused by ou
bast of enon: phe arte, sadn ca
‘roe one oft syngtins of aro
‘Cera Fleas, Wary Nexbly'n whch abo revs.
hare pce can son neal.
(Cecumstancatty Sone fining reeperaeg unneces-
$57 val tas. Evra he gato the ah
eared,
lang association. Szeecs i which wards ae chosen
couse ar Sound raer han Dar mange
Cuesiroptobie, Fear of beng tapped cated
‘poo,
Coma vigil rake, but wihout crass avareest.
is wepeabve slo parsons can cpen al esi
eemnaly tod demenerate seep use ele.
Tha also colt cna ncn,
Compuisen Cattonia, Waser ey, 2 endency
remain ina fed sticrozs sli fr long pts, he
‘tans my ges Way Bho pads eens
‘ctament
Compeision, Regetiwe russe bohavow o¢ mont
‘Concrete thinking. Thinking chrectraed snot exh
‘ily by write sensany experiance, rer an
cagnave teractions,
CCondensadon. Speed im whit two more separate
‘anon at eri
Conlaulaton psi bat aoa diny tat ly
'.gasit what stoner
Conta! Dalision The tee! tat cows thaghs
0s Were Under Se OSE CF
Dib ented. Subycteiy rapport inpcesion of
tomar of someting Jost hes wh unde
men ose.
eb pense. Siteciely iomcrrate impression of
femianty of samethig jst gn wi on une
‘mney oleae.
Die va Sua nape mers of antnty
‘ol apreson exprance wt a unenodpast
Deeviam 4 35 cannon wn ely ancien, wee
hg eco rae once oo
i
Dysarts. Dest pectin spo8eh
spo. Fein unweor nas.
Dysprasody A speech rose characterise aos
of een aliloaien ard yh
Eenalua Ts rpeti erweng of ital meses
mad by are person,
Echoprarie mck niaton te meovenents ot
‘nor. Ecpraiais.d50 an as econo.
cali. A sensation of beng cared avy by oven:
cain
Egamania Preersesbon whores
Etdete igen. Th sbi eta an sco, dts
‘aual image of canple soane or pattem (some
lives ppl bnown ae cekagraphic men.
‘rotomania, Excessive sexed dee, or exaggerates
‘sel on se conquests aby.
Eughare. Ra exaggerated tes weber oon.
Etim Noo nr rage re vet
a
-Fauss rconnsissnce, stusna le) canton of
porors rpaces
Fight of ideas. Spoesh canst of a sean of ace.
sed thogth wh aug anges fom pe bg
nd to cab Becta
Fate 4 deux. The shateg ofa assy by Wo Cosely
‘ssocines ends.
Foal thought csarder A dstrbane in te fom of
thea rite ta a orally of ertnt
Fugue 4 ceon whch an sit uy stan.
sons 2 peat atray or Mest od stats 9 ne
ant leet one apes fe
‘Gurtous, Gyn to escesie ond cen ti ot aing
tak; ora aah,
Global Aphasia, hols of a abil communicate
‘Giossoai Facies, meanings omen
‘Gratton Halucinaon,Hbcration ce
Malton Bos ean
Maluenoas. 8 otal site wah pst has
‘attra haonore.
‘MypermoesiaExrere power of meron. capac or
inmdste rgjroton and proce cal of much
rir deal hn & thai pattie wir ony
reste
yanagogic Hallucination Thesionoghatvonsiens st
‘hemarantf aing een.
Haiucinetin. Trestenieg talucratons
‘i h mometoyakng faHcp
Mypochondia. Henrmal ety shut ons heath:
ows’ neu earn toe OF
Dearne at
yteisl anwesthsia, Sensory ns. dis fo 8 menial
‘ae
Infidtty Oetusien. Th bet at ons pares some
ty nf,
amais ru The experience of being unin iy
eo sab at aly vy ay,
Jargon aphasia ncsoren meses spaces
[Labte: ected aod rai shits om one extame 8
shoter.
Liteten Hafucinaan, Haluchaton thot poole or
"bjs ae smb nthe ae
Loseenng ‘Ssch characters by soping fom one
tran of oogtt lo anober lowly read Ean ch
tout,
Mecrogala. Seng cvesing in etl cfview alae
‘taney 2
Maplea thinking. Ta bel at ons Bash, wots oF
actos wil caso of prowent a specie utc in
‘are ay thal does commonly undocd aus ch
ote
Meeps Sean eerytnng te eit von 8 salar
‘hanitreay
Monomania Precrapaion neha sgl ject
Hallucinations. Habcraton in woh
the cnr mood apgoptai.
Mood.ncengroentHalciations. Hstuinston in which
fhe conte cto ape.
Negatit,
‘vert cutie suggesions or ahr
Malai. Tse Mey mS8e up ed, oF a
vey lay Wo se an RO Hay
-nrsnc Douison. Te dots of avennce of 2
sel orpa fine set.
ows Ths tbl hate has die cag
‘Obsession A recut and persiti houp imps, or
‘mage
‘Overaled isn ueensonatle and susie beet
thal s manlaed wiles tan desalinony
‘Paani, Fis eecton or Pat Nave Bt
crue
-Persoveraon Mesa oerons cary on paste pi
hat ey serve acon. Eg. Wha ay 8 Mar
hy, What tive? Mendy.
Povey of Content Seach Bal crys ne eon
aca ts vague or barn
‘ore of Speech Less spect ts ror
Foren af thought Soeec bat cones ne beraan
becavse of vagenens, empty repeirs, or tee
typed ercbseur pases,
‘Prosopagnosia. Th iabity o recone fair fc,
‘Pugh they roe! pyselogealy 3 # ey do ecg:
nie he pon.
Pawsdodsnit hv um of preston ian
cee changes mie thse of ames,
‘Pseodoiogia fanasica, Gasly exnpering mecca
‘pions pos. doa
Peychomater Agiiton. Desctes 2 motid rene
‘seSon of mower presumed result fm paye
far han ghee ean) ehatance,
‘Realy tendog, Telack of sbly evans Px era
woe bee aed fo ererate away be
woe # and the ineal wei
‘arena Delusion 4 sion corres on ho es Pst
ets, ccs, ot pasar ane’ nace
thereporing of oct evel, mow he nl slain
mary of at was mano uy torented pow
sy.
Sensry Aphasia. cancion charac ty Rat tat
‘memingless speech and eves ingest of Be
hut undstind shen owe an wee
‘Somatic Delusion, A Sekscn whose ma ete per
ans 0 Be mpeatanoe of ncn cl ones ne
boy
‘Somatic Hallucination, Halucinaon invhing fo ma
te of bong arangis fosirg fat nsects ae rH
Ingbeneah he sin, eos of sen sian,
Somnoence A vey spy sat.
‘Syesihesieatucinadans, Th halucnston ota sree
‘her than the ons bang shai. For exanpl, =
saand may eke anaatone eu
Symacteal Aphasin Oout in arangea vents ne
came seqence
Systemadzed Delason & single ise tbe wth multe
‘Sucrasvs 4 goup os bases al epee
rele og sng even or heme
‘Tachurn Haast whi.
Tact Hallucination, Haron loch,
Tangetiaty Repirog fo gation 0 Bue oF
Trent Woy
“Thought broadcasting, Tete! Put ces tough ae
i beads Oat $0 Ba ey ca Be pe
caved by oer
‘Thought Insertion Te beet that oir ot one's
IRougrs ar not enes on, but rar ar neanes
na en's mi
‘Thought withdramat The bee! hat one wou ke to
ihe a thought bul samesne or someting has re
moved be Bett
‘Tee Pa ol he boy mes repented, gach, suddenly
and areola.
Traling Hatucnaions.Habcinason hat rc cts
ae tees as a tno acre Bicntro mages.
Trond ef houget Theke wes ondary tues or
‘tng ona paiodarden wh 3 pars alec
‘Unio mystica. The beset atone Ras yo en by
‘secret ie, More genera, the wit or won in
ual an ince wih hat Supreme Bag
sem ctor spar riser,
Wertigercive. imiirtayropeating of can words
ar pases
ial agnce The inaiy recog commen cbjcls
by sae
otibleDrminses conesston wth 2 ready tow ct
‘seed
Word seed. Specht an nchorent. and incre
hese el words ad pee,
emapobi Fo ef eager
‘Deophebia Fro ima