NORTH VALLEY COLLEGE FOUNDATION INC.

LANAO, KIDAPAWAN CITY

MENTAL STATUS EXAMINATION

Patient’s Name: _____________________ Name of Student:

____________
Name of Institution: ________________ Year & Section:
_____________
Date: ____________

I. PRESENTATION

A. General Appearance:
B. General Mobility:
1. Posture & gait: ( ) normal ( ) appropriate ( )
inappropriate
Describe:

2. Activity
( ) normoactive ( ) psychomotor retardation
( ) hyperactive ( ) agitated

3. Facial Expression
( ) smiling ( ) worried ( ) tearful ( )
frightened
( ) happy ( ) tense ( ) angry ( )
distant

C. Behavior:
D. Student Nurse-Patient Interaction
( ) cooperative ( ) uncooperative
( ) initially only ( ) all throughout ( )
sometimes

Quality
 ( ) warm ( ) distant ( ) suspicious
( ) talkative ( ) hostile ( ) others:

II. STREAM OF TALK (THOUGHT CONTENT)

A. Character of Talk
( ) spontaneous ( ) deliberate ( ) poverty of
speech
( ) not spontaneous ( ) echolalia ( ) word salad

B. Organization of Talk
( ) relevant ( ) irrelevant ( ) incoherent
( ) circumstantial ( ) tangential ( ) neologism

III. THOUGHT PROCESS (HOW CLIENT THINKS)

A. ( ) Delusion ( ) Flight of Ideas ( ) Obsession

Type:
Others:

B. Ideas of reference _______present

______absent
Preoccupation & rumination _______present ______
absent
Déjà vu and Jamais vu _______present
______absent
Homicidal potential _______present
_______absent
Suicidal potential _______present
_______absent

IV. EMOTIONAL STATE OF REACTION

A. MOOD: ( ) euthymic ( ) depression ( )

euphoria

B. AFFECT: ( ) appropriate ( ) inappropriate

Quality ( ) flat ( ) blunted ( )
hostile
( ) labile ( ) broad ( )
restricted
 Justification:

V. PERCEPTION

Describe:

A. Depersonalization & Derealization ______present

____absent
B. Illusion
______present ____absent

VI. NEUROVEGETATIVE DYSFUNCTION

A. Sleep: ( ) normal ( ) hypersomnia ( )

early insomnia
( ) late/terminal insomnia ( )
others

B. Appetite: ( ) normal ( ) increased ( )

decreased

C. Weight:
D. Attention Span: ( ) poor ( ) fair ( ) good

VII. GENERAL SENSORIUM & INTELLECTUAL STATUS

A. Orientation: ( ) time ( ) place ( ) person ( )

situation

B. Memory
Remote: ( ) unimpaired ( ) impaired
Recent: ( ) unimpaired ( ) impaired
Immediate ( ) unimpaired ( ) impaired
C. Calculations:

D.General Information:

E. Abstract Thinking:

F.Judgement: