Dictation File:____________________________

Dictation Date:________________
Clinical Interview – ADULT/Child Today’s Date:
Claimant:_____________________________________ Age:________ DOB:_______________
On SSI before: Yes No :___________________
Alleging disability due to/presents with:________________________________________________________________
Since when: ______________________________
Symptoms, duration, frequency, intensity:

Diagnostic Impressions/Summary: Meets criteria for ______________________________________________________

based on (observations; reported symptoms; current treatment and trmt history; test data, etc.) ___________________
__________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Prognosis:
Poor- chronic condition, lots of episodes, lots of hospitalizations; multiple treatments and no consistent improvement; can’t
function without assistance
Guarded – Could get better/could get worse, but why? Usually medical, substance use dis., poor trmt compliance hx
Fair – First episode, treatment not started or trmt effective in stabilizing condition; minimal support needed
Good – Adjustment disorders likely to resolve; symptoms managed with trmt; able to function with treatment;
little to no support needed to manage.
For good and fair prognosis:
___contingent upon receiving consistent psychological and psychiatric treatment given the claimant’s presentation and
psychosocial history
___ contingent upon receiving consistent educational support; tutoring; school accommodations; medical care
____ contingent upon other__________________________________
____open to treatment
MSE and Behavioral Observations
Age: _________, Race/Ethnicity___________
Height: Below Average Average Above Average Tall Short ______
Weight Thin Average Slightly Above Avg Obese _________
Client Arrived: Drove self____ Bus_____ Taxi_____ Other______
Accompanied By: Self_____ Relative_______ Friend_______ Significant other_____
Initial Attitude: Friendly___ Pleasant___ Shy___ Distant___ Apprehensive___
Guarded___ Angry___ Aloof___
Manner of relating: Cooperative Uncooperative Superficially cooperative
Rapport: Easily established___ Slowly established___ Variable___ Limited/Minimal___
Eye Contact: Good___ Adequate___ Variable___ Poor___ Staring___
Hygiene: Well groomed___ Moderately____ Minimally___Lacking in grooming___ Disheveled_____
Attire: Wore:___________________________________________________________________
Neat_____ Casual_____ Eccentric____ Seductive____ Torn/worn_____
Able to: Walk___ Sit___ Stand___
Gait: Normal___ Unsteady____ Shuffling___ Limping___ Stooped Forward___
Prosthetic Devices: None____ Hearing Aid____ Cane____ Walker____ Wheel chair____
Motor Activity: WNL___ Slow___ Tics___ Fidgety___ Restless___ Pacing___
Task Persistence: Very persistent___ Moderate___ Minimal___ Variable___ Needs encouragement___
Reported mood: “_____________________”
Euthymic Calm Depressed Sad Angry Anxious Labile
Observed Affect: Congruent Incongruent Labile Flat Blunted Inappropriate
Orientation: Month__________Day__________Year___________DOB________ City___________
Speech limits: Rate - Slow, normal, rapid ; Volume – soft, normal, loud, shouting; Tone – appropriate, angry,
intimidating, childish, other: _______________________________________________________
Speech Organization: Coherent___ Limited___ Disorganized___ Paused___ Pressured___ Hyperverbal___
Interrupted___ Slurred___ Soft___ Mumbled___ Stuttered___ Poor Enunciation___
Noticeable Accent____
Attention: WNL fair poor good variable
Observed: easily distracted lost track of question or thought redirection needed
Concentration: Good Fair Poor Variable
93, 86, 79, 72, 65, 58 97, 94, 91, 88, 85, 82
Serial 7s______________________ Serial 3s_____________________
10+5= 12-9= 8*3= 15/3=
Follows discussion Asks relevant questions
Information: Five large cities:_____________________________________
Current president: ____________3 priors:_____________________________
Thermometer: ______________________
What is water made up of:_____________________
Capital of Florida:_____________________
 Imm. / Recent. Forward Backward
Memory: House / Working Memory: 9-7 3-1
Ball /
Car / 6-3 2-4
Immediate: Good Fair Poor Variable 5-8-2 4-6
Recent: Good Fair Poor Variable
6-9-4 5-7
Long term: Good Fair Poor Variable
(As evidenced by): History in sequential order, details, dates, ect. ____________ 7-2-8-6 6-2-9

6-4-3-9 4-7-5
Abstract Reasoning: Similarities Proverbs
4-2-7-3-1 8-2-7-9

Hallucinations: Auditory Current History ex details: 7-5-8-3-6 4-9-6-8

Last X:
Frequency: 3-9-2-4-8-7 6-5-8-4-3
Visual Current History ex details:
Last X: 6-1-9-7-4-2-8 1-5-4-8-6
Frequency:
Other: Score: Score:

Delusions: None elicited paranoia persecution grandiose

Ex: ______________________________________________________________
Suicidal: Denied All Ideation Intent Plan__________________________
Hx of: ____________________________________________________________
Homicidal: Denied All Ideation Intent Plan__________________________
Insight: Fair Good Poor Judgment: Fire ex. Letter/Stamp ex. Wallet.

Competency: competent to manage funds not competent needs assistance/payee