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Mental State Examination
First Name:
Date of Birth:
Last Name:
Gender:
Male
Female
Other
Email Id:
Contact Number:
1. Appearance:
2. Attitude:
3. Behavior:
4. Speech:
5. Affect:
6. Mood:
7.Thought Processes:
8.Thought Content:
9.Perception:
10.Orientation:
11.Memory/Concentration:
12.Insight/Judgement:
Casual dress, normal grooming and hygiene
Other(describe:)
Calm and cooperative
Other(describe:)
No usual movement or psychomotor changes
Other(describe:)
Normal rate/tone/volume w/out pressure
Other(describe:)
Reactive and mood congruent
Labile
Tearful
Blunted
Normal range
Depressed
Constricted
Flat
Other(describe:)
Euthymic
Irritable
Elevated
Anxious
Depressed
Sad
Other(describe:)
Goal-directed and logical
Disorganized
Other(describe:)
Suicidal ideation:
None
Passive
Active
Homocidal ideation:
None
Passive
Active
If active:
Plan:
Yes
No
Intent:
Yes
No
Means:
Yes
No
If active:
Plan:
Yes
No
Intent:
Yes
No
Means:
Yes
No
Delusions
Obsessions/Compulsions
Phobias
Other(describe:)
No hallucinations or delusions during interview
Other(describe:)
Time
Place
Person
Self
Other(describe:)
Short term intact
Other(describe:)
Good
Fair
Poor
SUBMIT
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