University of Santo Tomas

College of Nursing

Mental Health and Psychiatric Nursing

Comprehensive Mental Health Assessment Form

Demographic Data
Name (Initials) M.V Age 24 Gender F Marital status S _
Address Tondo, Manila Birthdate November 4, 1996 _
Admission data
Date and time of admission February 20, 2021; 8 am _
(1) Reason for Admission
As perceived by patient The patient said that she was there because of violent episodes where he
threw a stapler to his boss and obsessively buys anything. _
_
According to relatives___________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
(2) Previous psychiatric history
Dates: _
Reasons / diagnosis: None _
Type of treatment received_______________________________________________________
(3) Drug and Alcohol use / abuse
Amount: N/A _
Frequency:___________________________________________________________________
Duration of past and present use of legal / illegal substance N/A _
Date and time of last use________________________________________________________
(4) Disturbances in patterns of daily living
Sleep Patient verbalized that she feels well-rested with only 1 hour of sleep and does not feel the
need to sleep more than that. _
Intake Patient verbalized that she has no problem with food and water intake. _
_
Elimination Patient verbalized that she has no elimination problems _
_
Sexual activity Patient is not sexually active _
_
Leisure Patient verbalized that she likes to watch netflix and movies. She also said that she has a
lot to do at their house and it keeps her preoccupied and busy. _
Self-care and hygiene Patient practices good hygiene and verbalizes that she takes a bath _
everyday. _

(5) Spirituality
Religion Catholic _
Beliefs and practices The patient did not say any further belief than that of being a Catholic _
_

(6) Support system

The patient’s support system is her family. _
_
_
_
 MENTAL STATUS EXAMINATION
(7) General appearance: Type and condition of clothing, cleanliness, physical condition, posture, gait,
facial expression, eye contact, general state of health and nutrition
The patient is presentable and is wearing decent clothing. The patient also has proper grooming and has
good posture and gait. The patient’s facial reactions are appropriate and she can sustain eye contact. The
patient verbalized that she has no underlying diseases. _
_

(8) Behavior during the interview:

Expression of anger: covert, overt, physical
Degree of cooperation, resistance, or evasiveness
Social skills: positive / unpleasant habits, shyness, withdrawal
The patient is cooperative, overt, and positive _
\ _
_

(9) Amount / type of motor activity:

⬜
Level of Activity

⬜ Psychomotor retardation ⬜ Others _____________________________

☑️
⬜
Agitated
Restlessness

⬜ Tensed
Hypervigilance

⬜
Type of activity

⬜ Tics ⬜
Others _____________________________

⬜
☑️
Grimaces
Tremors

⬜ Compulsions
Unusual gestures / mannerisms _________________________________________________

(10) Speech Patterns

Rate ☑️
☑️Rapid ⬜ ⬜
Amount: (muteness, paucity, loquacious)
Slow
Volume
Characteristics ⬜ Loud
Slurring ⬜ Soft
Stuttering
Others: _______________________________________________________________________
(Describe any unusual speech pattern)
______________________________________________________________________________

(11) Degree of Concentration, Attention Span and Calculation:

(Count from 1-20 rapidly, serially subtract or add from 100)
The patient can count rapidly from 1 to 20 and can solve simple mathematical problems. _

Orientation: ☑️
☑️ Time (What is today's date?) February 20,2021 _

☑️ Person (What is your name?) was able to correctly state her name _.
Place (Where are you today?) NCMH, Mandaluyong

(12) Memory: Remote (Recall events/information from distant past)

 The patient can recall information from the past when asked about a memory from
childhood. _
Recent (Recall events of the past 24 hours or past week) / remote, amnesia, blackouts
confabulation She can recall what she did for the past 24 hours, but keeps saying she
needs to go home. _
Immediate (Repeat a series of numbers either forward or backward within a 10-second interval)
The patient was able to corrrectly repeat a series of number forward and backward within

Others:
Thought Clarity:
⬜ ☑️ ⬜ ⬜
10 second interval.
Blackout Confabulation
Coherence Confusion
⬜
⬜ Amnesia
Vagueness
_

⬜
⬜ Blocking ☑️
(13) Thought Processes reflected in speech:

⬜ Perseveration

⬜
☑️Echolalia ⬜
Circumstantiality

⬜
Verbigeration
Tangential Ideas

⬜
⬜ ⬜
Flight of Ideas
Loose associations
Word Salad
Ambivalence
Neologism

The patient keeps saying that she would be running for president and that she is rich and likes
greenwich. She also keeps on changing from one topic to another like saying that she gets into
argument with her sister and that she is irritated with her boss. _

⬜
(14) Thought Content:
Feelings of hopelessness, helplessness ☑️
⬜ ⬜
Compulsions

⬜
⬜
worthlessness, guilt
Suicidal ideas / plans
⬜
Preoccupations
Antisocial attitude

⬜
⬜
Homicidal ideas / plans
Suspiciousness ⬜
⬜
Blaming of others
Poverty of content

⬜Phobia
Obsessions
Denial

Description: The patient keeps saying that he has a lot to do at home and has no time to be
doing other things. _

☑️
(15) Hallucinations

⬜ Auditory

⬜ Visual
Others (specify)________________________________________________________
Content The patient says that we must keep their voice down because there are a lit of
people listening. _

(16) Delusions
☑️
⬜ Grandeur ⬜
⬜ Influence

⬜ Religious
Reference ⬜ Somatic
Persecution

Content: The patient keeps saying that she is rich and would be running for president in
2022. _

(17) Information and Intelligence

Educational level: College graduate _
 (Ask to list similarities, interpret a proverb or assess general information knowledge)
She knows general information and was able to answer the questions correctly. (e.g. Who
is the president this year? Where does the president resides?) _

(18) Affect / Mood

Anxiety level: ⬜ Mild ☑️ Moderate ⬜ Severe ⬜ Panic
Affect: (statement of emotion) ☑️ Appropriate ⬜ Inappropriate ⬜
⬜ Restricted ⬜ Blunted ⬜ Flat ⬜ Labile Adequate

☑️ Euthymic ⬜ Elevated ⬜ Depressed ⬜ Labile

Mood: (prevailing emotional state) Ask: "How are you feeling today?"

⬜ Poor ☑️ Good
(19) Insight: (degree of awareness / understanding of problems and their causes)

The patient is aware of the problems in our society. She is aware that there is an ongoing
pandemic and people have to keep their distance form one another. _

(20) Judgment: Soundness of problem solving and decisions (e.g. Ask "What will you do if you
entered your house and smelled gas?)
The patient answered correctly by saying she would wear mask and faceshield when asked what
she would if she goes outside during the pandemic. _

GUIDE IN RATING:

95 – 100 EXCELLENT Able to execute the procedure and ask specific questions
without mistake; observes the basic principles of intake
interview/ mental health assessment effectively
90 – 94 VERY GOOD Able to execute the procedure and ask specific questions
properly with very limited mistake; adequately observes the
principles of intake interview / mental health assessment
85 – 89 GOOD Able to ask specific questions however, needs to add more to
substantiate the parameter.
80 – 84 SATISFACTORY Able to ask specific questions well but some questions need to
be rephrased or clarified
75 – 79 FAIR Needs more guidance and practice in performing intake
interview