Mental Status Exam Form

Client Stature
below average above
average average
Date Coordination and
Gait used a cane
no difficulties

Ethnicity some anxiousness and awkward

restlessness staggered
some clumsiness shuffling
Apparent Age Grooming
younger stated age older good satisfactory
neglected adequate
Handedness
poor
Right Left
Dress
Sex
casual stylish
male female
ok for work ok for weather
Build ok for age dirty
average thin
underweight petite
healthy stocky

Interpersonal Style Speech

congenial
engaging understandable/clear fluent/easy to
guarded
hostile coherent/meaningful understand
open/candid
somewhat shy normal rate/volume clear/logical
patient/cooperative
open and motivated appeared thoughtful variable rate but clear
friendly/polite
relaxed/unconcerned abundant/excessive used a loud voice
quiet/withdrawn
cautious/defensive overly friendly animated/confident
distant/disengaged
irritable/guarded simple/soft-spoken mumbled
annoyed/irritable
stuttering difficulty finding words
Repeated Questioning included profanity poor articulation
critical/sarcastic pressured/fast-paced
yes no catch phrases and slurred/hard to
Approach cliches understand

cooperative impoverished w/ little

dependent
conscientious detail
motivated/focused
unconcerned
apathetic/careless Eye Contact
passive/unassertive
resistant and defensive good normal
negativistic/critical
careless and sloppy fleeting avoided
hurried
needed brief contact quickly
lethargic
minor/considerable broken
uncertain/somewhat
reinforcement and
anxious/declined to
soothing Conversation
guess
interested/thoughtful could initiate and hold no difficulties
compliant but poorly
unwilling to engage difficulty finding words
motivated
hesitant unable/able to
use of odd or bizarre comprehend questions
words
note if English is not primary language, comment on
command

Recall of Personal Hx so e difficulty adequate detail

no difficulty m sparse detail
Recent Past
Recall Of 3 Words
(like Cadillac, Purple, and
Zebra)
3 2 1 0
Prompting Helped
yes
Examiner's Name
remembered
Certainty of Information
probably true
Alert/Oriented
alert and oriented
distracted
no distractibility
high distractible
Attention and Concentration
(Serial 3s or 7s, "WORLD", days or months backwards)
satisfactory
adequate or sufficient
variable, likely due to
apparent depression
no sig impairment
mildly deficient
Motivation
poor motivation
inconsistent
Communications
honestly coherent confusing
clear/understandable
some reluctance reluctant and hesitant
lacking in needed overly detailed and
detail difficult to follow
normal level of detail
avoided certain Relevance
topics clear and appropriate off-topic
on-topic relevant
irrelevant/inappropriate tangential/unrelated
Thought Processes
organized confusing/difficult to
no
concrete/simplistic follow
strained/illogical suspiciousness or
forgot clear/understandable paranoid reasoning
no loose associations no pressured speech or
preoccupations obsessive thoughts
veracity is doubtful perseverative no difficulty explaining
poorly thoughts and finding
organized/difficult to words
basically oriented follow most of time no indications of a
no impairment some disorganized formal thought
imperfect reasoning disorder
tired/from working
late Hallucination and
Delusions no history except
no history associated with drugs
some history no history, but some
evidence
sample proverbs
A rolling stone gathers no moss
In the land of the blind, the one-eyed person is king
poor All that glitters is not gold
distractible Don't count your chicken before they hatch
adequate Don't put all your eggs in one basket
adequate, with Strike while the iron is hot
occasional distractions Rome wasn't built in a day
mild to mod When the cat's away the mice will play
impairment A stitch in time saves nine
You can dress a monkey in silk but it's still a monkey
("Aunque la mona se vista in seda...")
did not improve
easily weakened sample sayings
What would I mean if I said I were feeling blue?
seeing red? I had a chip on my shoulder? or was hot
under the collar?
sample duplicate definitions
left, bit, right
Judgment and Intellectual Ability
good, able to
anticipate outcomes
adequate, able to use
feedback to learn from
mistakes
fair, able to learn from
some experiences
poor, difficulty
predicting results of
choices
Memory
roughly average, above reported problems denied problems
average, or below could/could not recall difficult to understand
average plot of favorite movie line of reasoning
based on ?s like "name or book logically
last four presidents,"
"who is the governor of
the state," "what is the
capitol of the state,"
"what direction does
the sun set" ...

Abstraction
poor, adequate, good, based on proverbs and
sayings, similarities, and duplicate definitions for
words

Mood and Affect

Displays of Inappropriate Affect
(Climate and Weather)
yes no
calm and composed
anxious
reserved Suicidal/Homicidal Thoughts
bored and
seemed depressed disinterested denied reported
irritated upbeat and denied, but noted...
somewhat agitated elevated generally
Response To Failures
relaxed/untroubled
unconcerned by satisfied to accept
initially calm, but
unaware of annoyed by
became...
demoralized by distressed by
Expressions able to recover after unmotivated to
ir/relevant somewhat subdued frustrated over improve after
in/appropriate labile
Response To Rapport
normal consistently happy
easy difficult
flat consistent w/ reported
easy after anxiety easy then difficult
mood
decreased easily upset
Apparent Emotions tenuous
annoyed defeated
Audio Comment
calm shameful
audio-taped poor motivation
resentful defended
administration skipped some
anxious unfairly treated
depressed and poor questionnaires
agitated
concentration questions read by
Facial and Emotional Expressions poor comprehension examiner; answers
relaxed sad taken by dictation
tense alert
smiled day-dreamy
laughed angry
became insulting smiling
yelled distrustful/suspicious
happy tearful when discussing
such and such

Form by Richard Niolon, Ph.D., www.psychpage.com