MENTAL HEALTH ASSESSMENT FORM

DEMOGRAPHIC PROFILE

NAME: De Guzman, Aurora G AGE: 56 GENDER: Female MARITAL STATUS: Widowed

ADDRESS: 704 A-13 Apelo Cruz St Brgy 157 Zone 16 Pasay City
DATE OF BIRTH: Dec 12 1967 BIRTHPLACE: Pasay City
CONTACT NUMBER: 09662972141
EDUCATIONAL ATTAINMENT: Grade School Completer
OCCUPATION/PROFESSION: Housewife
RELIGION: Roman Catholic

APPEARANCE: COMMENTS:
A) POSTURE
Healthy Posture __
Kyphosis __
Lordosis __
Flat Back __
Forward Head __
B) BODY MOVEMENT
Normal – voluntary, deliberate, coordinated, smooth and even ___
Anxiety – restless, fidgety ___
Depression – apathy, slow movements ___
Schizophrenia – bizarre gestures, facial grimaces ___
C) DRESS
Well dressed ___
Undressed ___
Overdressed ___
Underdressed ___
D) GROOMING AND HYGIENE
Clean and Well-Groomed ___
Soiled ___
Body Odor ___

BEHAVIOR COMMENTS:
A) LEVEL OF ALERTNESS
Alert ___
Lethargy ___
Stuporous ___
Comatose ___
B) FACIAL EXPRESSIONS
Appropriate ___
Inappropriate ___
C) SPEECH
Normal ___
Emotional ___
Hesitant ___
Pressured ___
D) MOOD & AFFECT
Normal ___
Euthymic ___
Anxious ___
Angry ___
Irritable ___
Depressed ___

COGNITIVE FUNCTIONS
A) ORIENTATION
Time:
Day:
Place:
Person:
Self:
B) ATTENTION SPAN
Attentive ___
Distracted ___
Disoriented ___
C) MEMORY
Short Term Intact
Long Term Intact
D) NEW LEARNING
“Four Unrelated Word Test”
To the patient: “I will say 4 words. I want you to remember them.
In a few minutes, I will ask you to recall them.”
Pick 4 words with different semantic and phonetic as follows:
1. Mask 2. Omelet 3. Astronaut 4. Nails
1. Blue 2. Saint 3. Dinosaur 4. Engineer
1. Diamond 2. Car 3. Darna 4. News
RECALED:
5 mins
10 mins
30 mins
 E) JUDGEMENT
GOOD ___
FAIR ___
POOR ___

THOUGHT OF PROCESS & PERCEPTION

A) THOUGHT PROCESS
Goal oriented & Logical ___
Disorganized ___
B) THOUGHT CONTENT
SUICIDAL:
None Passive Active
HOMICIDAL
None Passive Active