MENTAL STATUS EXAMINATION Name: [ao Mork S- Gonlonsto Date: 2/22| Bay a we Genders | ‘Admitting Date of [ny 5 oan Diagnosis: ‘Admission: |!” {nstruction: Check the box that corresponds to the signs and symptoms manifested by the client L General Appearance Appearance in ][JAppear younger to JC] Appear older to [2] Appear relation toage: | age age normal to age Accessibility Friendly IL Hostile Tothers (Alert It Confused Ll Cooperative I) Indifferent Body Build [alta Thin Clweight (short (C] Obese Clothing “Appropriate to: [Eiclean Bright | Jothers ‘Age [Gneat colorful [5 Season [Otidy but [Setting [Meticulous [Occasion [Worn Cosmetics Applied [None Clothers = Properly [2 carefully Careless! Hygiene and Clean \Ciun-bathea Titthers Grooming Dirty/Soiled Meticulous Odor Perspiration [alcohol Dothers pus On Foul cologne Pungent C)shaving Lotion Facial Expression | Appears: Cothers )sad (suspicious J Perplexed (smiling [Worried Erresponsive (CI Fearful (interested Excited (Canimatea Elated (Blank Preoccupied (Dazed (Bored Tense Eye Contact Indirect [CGlaring Others 2 Eres Edarting el Fleeting [CINo contact Psychomotor Behavior Brisk i aie Eperise = [Uncoordinated xesitant [Normal ee Propulsive Ataxie a Handshake 00" [ClFirm weak = Refused Heavy _ : MITTIN NOW: NO AOMITTING Arenas ON Panett Caer 64]Warm cool Pri _— Rees Seger 5 flame al Maven 4 oe a ‘wringing Echopraxia s itualistic behavior [>] Others Twitches Mannerisms Foot Tapping Posturing Nail biting Chewing movements Posture stoped Shaky a letRelaxed [Clstouched Fothers suit (Bizarre [F Posturing mannerisms Rate of movements Scena [Dilivperactive — (CpRetarded Clothers Slow (agitated Coordination of Awkward Falling easily Others Movements Clumsy Gagite fz Communication Rate of Speech Rapid Slow Doordinary Flow of Speech LetHesitant [stuttering Forgetful soersve lng ones Eien (jerky Halting Long pause Intensity of Volume [_]Loud [Whispered [others Soft (Cvelling Ordinary [Giinauaible : r Lispit Tacoherent San ESsturea anting Others Mumbled (Relevant a Intense formal Liveliness BA nC eae Others Monotonous_|CJEx ese 5 aa ids onl Offers information petitive OE, Sees 7 Eiscant Others ‘Verbose (Mute —— ‘Thought Process and Content Clarity Confused Relevant Others Relevance oF Irrelevant fs Logical Excited Reaction to questions: [_] Others Bow Flight of ideas ‘Normal Tangentiality Rap! Poverty of [Blocking thoughts Mutism Word salad Echolalia ‘Clang (CINeologisms associations Pressured speech ‘Slow ircumstantiality Doubting pontaneous Indecision _ 65Pitoose [CI Continuity of association thought [1 Blocking ‘ Perseveration content Poverty of [Bizarre ‘Suicidal ideation: thought CJ systematized E1None (CJovervalued idea |] Mood-congruent CoPassive IC Trend of thought | Mood-incongruent DActve (CJ Egomania [SI Nihilistic [Monomania [1 Somatic Nace (Hypochondria {letParanoid ea 8 8 op: Intent o session (CJ Persecutory Means C] CJ (J) Compulsion (Grandeur [Nees (J Referential Homicidal (Junio mystica —_[C)Self-accusatory ideation: (CJ Rhymes (control C1 None [Puns thought CPassive 2unreality withdrawal oe [illusions [Thought Itactive: YES NO [tHallucinations _| broadcasting Plan [7 Ideas of J Infeidelity Intent reference [Cl Erotomania Means [J] CI [Preoccupations |] Pseudologia oO Tantastica [Dothers Depersonalization a [Delusions Mood and Affect ‘Appropriateness of [Appropriate to [LJCongruent Diothers affect situation Cimcongruent Inappropriate to situation o Co jBlunted thers Range of affect [Eisuperfcial Constricted_ [Citable Others Ang Withdrawn “Attitude towal a EB om [Clothers nurse during ‘Warm |] Defensive encounter [playful (] Seductive (ClGuarded Friendly Ba leasant yerly familiar xepoperative (ClFear Jothers: \CetRegret feelin |Anger CJElation or reporte' Optimistic IMiserable Pessimistic Puzzled elessness. epressed, Severe 66[LModerate Panic 2 Sensorium and InteJJectual Process ‘Attention and Sufficient ‘Adequai Concentration Deficient cand rere (Cleasily \C)Preoccupation distractible (CiSerial 7s test (CiShort span of —|[JMonths of the year attention backwards Poor concentration Memory (Short Recent events of — [(]Localized amnesia | Able to term & Long term) | last few ([lGeneralized remember: hours/days: amnesia IC Family Poor [CSelective amnesia | birthdays Average [Continuous [Cl Country Remote events of || amnesia capitals past year: (C) Paramnesia | 5 minutes [41 Poor (C_) Déja entendu recall of name [Flaverage [gia pense and address (gia vu [Codigit span [jamias vu tests CD typermnesia (J Eidetic images (Clothers concrete ‘Able to think Others ‘Abstraction a abstractly 7 Oriented to: Not oriented to: [Clothers Orientation fenee rime at Place an > Mild Retardation |] Profound [Others Intelligence (EModerate Retardation retardation Dementia Severe |] Pseudodementia ion iF aa ed (Citwilightstate __[J0thers Consciousness esi Dreamlike state [Cisomnolence (CDelirium ‘and Insight JZ Abletocometo |JOthers ‘appropriate conclusions decisions [Climpaired Critical ‘Automatic ipaired insight |CAIntellectual insight [LJ Others Denial of C2) True insight disorder 67External locus of disorder Sel Ego Boundaries Jflacks feeling of Others uniqueness confusion on his/her identity Echolalia ID Echopraxia Body distortions (A ideas of reference B Depersonalization CDerealization i téentification | Imitation Bizarre behaviors [X{Public ‘Speaking about self Plotters undressing in the third person [Masturbating {Cl Physically clinging to objects in the environment Roles and Relationships Disturbance [ZSocial isolation —[_] Withdrawal others Hostility [Inadequate or am improper communication ‘Summary of Mental Status Examination A Disturbance in: [Presentation [21Emotional state and []Neuro- ] (Clstream of Talk reaction vegetative [EtThought contro! —_| dysfunction (Etceneral | sensorium and. | intellectual status B. Diagnostic Functional sychotic (Cakaone Organic Non-psychotic aeert pin SBE ‘Name & Signature of Examiner Date Score: 100 68