Brief Mental Status Exam (MSE) Form



Brief Mental Status Exam (MSE) FormMember Name: FORMTEXT ?????UCare ID #: FORMTEXT ?????Date: FORMTEXT ?????Care Manager Name: FORMTEXT ????? FORMCHECKBOX UCare FORMCHECKBOX Other Partner: FORMTEXT ?????Appearance FORMCHECKBOX Casual dress, normal grooming & hygiene FORMCHECKBOX Other (describe) FORMTEXT ?????Attitude FORMCHECKBOX Calm & cooperative FORMCHECKBOX Other (describe) FORMTEXT ?????Behavior FORMCHECKBOX No unusual movements or psychomotor changes FORMCHECKBOX Other (describe) FORMTEXT ?????Speech FORMCHECKBOX Normal rate/tone/volume/ w/out pressure FORMCHECKBOX Other (describe) FORMTEXT ?????Affect FORMCHECKBOX Reactive & mood FORMCHECKBOX Normal range congruent FORMCHECKBOX Labile FORMCHECKBOX Depressed FORMCHECKBOX Tearful FORMCHECKBOX Constricted FORMCHECKBOX Blunted FORMCHECKBOX Flat FORMCHECKBOX Other (describe) FORMTEXT ?????Mood FORMCHECKBOX Euthymic FORMCHECKBOX Anxious FORMCHECKBOX Irritable FORMCHECKBOX Depressed FORMCHECKBOX Elevated FORMCHECKBOX Other (describe) FORMTEXT ?????Thought Process FORMCHECKBOX Goal-directed & Logical FORMCHECKBOX Disorganized FORMCHECKBOX Other (describe) FORMTEXT ?????Thought Content FORMCHECKBOX Suicidal ideation FORMCHECKBOX None FORMCHECKBOX Passive FORMCHECKBOX Active Y NIf Active: Plan FORMCHECKBOX FORMCHECKBOX Intent FORMCHECKBOX FORMCHECKBOX Means FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Homicidal ideation FORMCHECKBOX None FORMCHECKBOX Passive FORMCHECKBOX Active Y NIf Active: Plan FORMCHECKBOX FORMCHECKBOX Intent FORMCHECKBOX FORMCHECKBOX Means FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Delusions FORMCHECKBOX Obsessions/compulsions FORMCHECKBOX Phobias FORMCHECKBOX Other (describe) FORMTEXT ????? Perception FORMCHECKBOX No hallucinations or delusions during interview FORMCHECKBOX Other (describe) FORMTEXT ?????Orientation FORMCHECKBOX Oriented X 3 FORMCHECKBOX Other (describe) FORMTEXT ?????Memory/Concentration FORMCHECKBOX Short Term Intact FORMCHECKBOX Long Term Intact FORMCHECKBOX Distractible/Inattentive FORMCHECKBOX Other (describe) FORMTEXT ?????Insight/Judgment FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX Poor ................
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