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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 Compulsion BZ 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 Ps Selected 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

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