MENTAL STATUS EXAMINATION Name: _____________________________ Date: ___________

Appearance: Looks stated age? Yes No Ht: ________ Wt: _________

Body build: thin medium obese emaciated muscular frail
Posture: rigid slumped cross-legged slouched comfortable edge of seat leaned forward
Eye contact: none appropriate staring
Dress: Casual Business Attire Formal Appropriate? Yes No
Grooming: WNL malodorous highly perfumed dirty smell of alcohol hairstyle makeup
Manner: cooperative guarded seductive inappropriately familiar hostile
Attentiveness: disinterested distractible attentive

Motor: :1/ slowed movements unable to sit still wringing hands pacing
Abnormal movements: None
tremor lip smacking tongue thrust grimaces tics
Gait: WNL shuffling limping unsteady

Speech: 5DWH: :1/VORZ long pauses  rapid pressured 5K\WKP: :1/ monotonous Vuttering
9ROXPH: WNL loud soft whisper
3URGXFWLYLW\: monosyllabic
WNL hypertalkative mute responds to direct questions only
$UWLFXODWLRQ: clear mumbled slurred

Mood: _________________________

Affect: DSSURSULDWH IXOOUDQJHUHVWULFWHGFRQVWULFWHGODELOHIODWH[DJJHUDWHG

6XLFLGDO,GHDWLRQ Yes No +RPLFLGDO,GHDWLRQ Yes No Intent Yes No Plan Yes No

Thought contentdelusions erotic delusions grandiosity ideas of reference magical thinking

paranoia thought broadcasting thought insertion obseVVLRQV2ther: ________________________________

Thought process: goal-directed logical coherent loose associations rambling

word salad circumstantiality tangentiality perseveration flight of ideas

Perception: $XGLWRU\ 9LVXDO 7DFWLOH .HQHVWKHWLF *XVWDWRU\2OIDFWRU\

Intellect: below average average above average

Orientation: Person Place Time Situation

Memory: Immediate Recent Remote

Attention: Alphabet World Concentration: Months Serial 7s Serial 3s

Fund of Knowledge: 3 Presidents 1 2 3

th
4 of July # days in a year Martin Luther King Jr. famous for

Abstraction You cant judge a book by its cover.

People who live in glass houses shouldnt throw stones.
Dont count your chickens before theyre hatched.

Judgment What should you do if you find a purse or wallet in the street?
Why do we put stamps on letters we mail?
Why do we have to have license plates on vehicles?

Insight Why are you seeing me today? __________________________________

Do you think you are ill?
Do you think you need treatment?

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