Mental Status Exam

Name:       CID#:      

Check more than one descriptor if applicable. Elaborate on any problem areas in the space provided.
Appearance & Hygiene Meticulous Neat Clean Disheveled Bizarre Body Odor
Comments:      

Motor Activity Appropriate to situation Over-active Tremor/tics Poor coordination Repetitive Lethargic
Comments:      

Attitude During Interview Cooperative Oppositional Hostile Dramatic Guarded Irritable Withdrawn
Comments:      

Affect Appropriate to situation Blunted Flat Tearful Incongruent Expansive Labile

Comments:      

Mood Happy Euthymic Anxious Depressed Angry Hopeless Suspicious Passive

Comments:      

Speech Normal rate and tone Slow Fast Soft Loud Pressured Slurred Stuttering Alogia
Comments:      

Thought Process Normal, appropriate, coherent, relevant Loose associations Flight of ideas Blocking Racing
Circumstantial Tangential Indecisive Disorganized Concrete
Comments:      

Thought Content Normal Phobias Obsessions Ideas of hopelessness Ideas of worthlessness Paranoia
Persecutory Suicidal Homicidal (Note: If suicidal or homicidal, see risk assessment)
Comments:      

Hallucinations No evidence Auditory Command Visual Olfactory Tactile Denies

Comments:      

Delusions No evidence Persecutory Grandeur Reference Influence Somatic Denies

Comments:      

Orientation/Level of Alert Oriented to Person Place Time Situation

Consciousness Clouded Confused
Comments:      

Judgement Able to make sound decisions Usually able to make sound decisions
Poor decision making, adversely affects self Poor decision-making, adversely affects others
Comments:      

Insight/Adjustment to Denies problems/illness Blames others Minimizes Acknowledges & understands

Problems/Illness, Acknowledges but fails to understand
Disabilities, Disorders Comments:      

Memory Intact Poor remote Poor recent Poor immediate

(use example ) Comments:      

Concentration & Able to concentrate Able to do simple math Easily distracted Daydreams
Calculations Comments:      
(use example)
Fund of Knowledge Above average Average Below average
(use example) Comments:      

Other Pertinent Information:      

Sleep Patterns: Appetite/Eating Patterns: Energy Levels: Libido
Adequate Hypersomnia Adequate Purges Adequate Adequate
Early awakening Insomnia Increased Binges Increased Increased
Short intervals Sleepwalking Decreased Doesn’t eat Decreased Decreased
Nightmares Decreased need for sleep Weight changes:     Lbs. Fatigue
Other      
Clinician’s Signature/Title Dat      
SCDMH FORM e:
OCT 2008 (FM 04 27 2009) C-192 See CSN:       See back for additional comments.
additional comments
     

SCDMH FORM
OCT 2008 (FM 04 27 2009) C-192