MENTAL STATUS EXAM - PGU

MENTAL STATUS EXAM

Date:____________ Client Name: _______________________________

Partner Status _________

Age:_____

Sex:____

Ethnicity:______

Occupation _________________ Sexual Orientation _________________

Number of children _____________________________________Living Circumstances ______________

GENERAL

Appearance

Hygiene

Clothing-Grooming

Physical Characteristics

Average

Average, Appropriate

Weight: Average, ¡ü , ¡ý

Unique marks (tattoos)

Unclean

Unkempt, Disheveled

Health: Good, Frail

Body type-build

Body odor ¨C Unusual

Atypical

Unusual

Physical Disabilities

General Behavior & Mood

Eye contact:

Yes ¨C Appropriate

Sometimes

Posture:

Relaxed

Slumped

No

Inappropriate: staring

Rigid

Motor Activity

Agitated, Fidgety Restless,

Pacing,

Fear, Anxious

Anger, Hostile

Appropriate, Audible

Appropriate, Controlled

Appropriate, Concise

Appropriate, Clear

Alert

Decreased, Slowed.

Psychomotor retardation

Sadness , Depression

Joy, Reflective

Soft, Mute,

Rapid, Pressured, Slow

Monosyllables. Minimal

Stutters, Slurred, Mumble,

Lethargic, Drowsy, Stupor

Unusual: Tics, Tremors

mannerisms, gestures

Unusual, Atypical

Absence of feelings

Loud

Deliberate, Monotonous

Detailed, Elaborate

Impediments ¨C ESL

Unresponsive. Even to pain

Facial Expression

Speech Volume

Speech Rate

Speech Quantity

Speech Quality

State of Consciousness

Attitude Towards Interviewer

Cooperative, Open

Control, Domineering

Oppositional/ Provocative

Genuine. Attentive

Hostile

Overly Compliant

Suspicious, Guarded

Resistant, Evasive

Clinical Narrative Re General Example: ¡°Mrs. Andrews appears older than her stated age of 50, she is considerably overweight,

and was dressed in a soiled sleeveless dress that seemed inappropriate for the cold, rainy weather. Her hair appeared dirty and

tousled. Though cooperative with the interviewer, she sat tensely in her chair, avoided eye contact unless addresses directly, and

wrung her hands throughout most of the interview.¡±

FEELINGS

Predominate Mood: How do

Reflective

Euphoric

Elevated

you feel most of the time?

Depressed, Dysthemic

Angry

Irritable, anxious

Affect: How is mood

Broad and appropriate

Restricted, limited range

Blunted

expressed?

Flat

Inappropriate

Labile, tearful, crying

Appropriateness to Thought

Mostly congruent

Sometimes congruent

Not congruent

Content

Mood and Affect Word Vocabulary: Euphoric, elated, frivolous, buoyant, jovial, light-hearted, cheerful, placid, sober,

serious, solemn, grave, gloomy, brooding, disconsolate, hopeless, terrified, panicky, agitated, tremulous, apprehensive,

tense, fretful, uneasy, composed, calm, non-chalant, unconcerned, cool, bland, stoic, self-condemning, self-reproachful,

remorseful, ashamed, regretful, concerned, indifferent, unfeeling, unreformed, derogatory, scornful, argumentative,

critical, outspoken, frank, tactful, soft-spoken, complimentary, flattering, assaultive, assertive, hesitant, passive, tender,

sympathetic, kindly, considerate, unresponsive, detached, unfeeling, hardened, rejecting, agreeable, reserved, bashful,

reticent, withdrawn, excitable, abrupt, restless, eager, satisfied, restrained, indifferent, listless, lethargic, persistent.

PERCEPTION (OF SENSORY INFORMATION)

Hallucinations ( no stimulus is

present). Do you hear voices

when no one is around

Illusions (misperceived

stimulus)

Derealization: Sense of

detachment from one¡¯s

world/environment.

Depersonalization: Sense of

detachment from one¡¯s sense of

self. Often an experience of

anxiety.

Astereognosis

APRAXIA:

None

Visual: Do you see?

Olfactory: r/o brain tumor

or disturbance.

Auditory: Do you hear? Do

you follow the voices?

Gustatory. Do you have

unexplained sensations

None

Present

No Data

None

Present

No Data

None

Present

No Data

No Data

Identifies by touch

Does not identify object

No Data

Difficulty carrying out purposeful voluntary movement sequences for speech in the absence of

paralysis of the speech musculature.

THOUGHT PROCESSES

Stream of Thoughts

Productivity

Continuity

Language and Speech

impairment:

Content Of Thoughts

Preoccupation

Average

Spontaneous

Goal Directed, Logical

Perceptive

Peseveration of thoughts

Overabundance

Paucity

Needs prompting

Mixed

Relevant ¨C Irrelevant to

Loose associations, Rambling

question asked

Effort to go from thought to

Tangential,

thought

Blocking, Vacant stare

Flight of ideas

Circumstantial

Neologisms ( makes up

Word Salad (inClang association (meaningless

new words)

comprehensible speech)

word rhymes)

Anomia: Cannot name objects,Apraxia:

cannot Difficulty in

Echolalia ( word echoing )

recognize spoken objects

carrying out sequential

Incoherent

speech

Aphasia: Impairment of language, affecting the production or comprehension of speech and the

ability to read or write. Aphasia is always due to injury to the brain-most commonly from a

stroke.

Obsessions Compulsions

Phobias. Paranoia.

Persecution

Repetitive thoughts-worry

Somatic concerns:

Intrusive worries about

disease or defects.

Thought Disturbances

Delusions: false beliefs:

Ideas of reference: Those

Do you have thoughts

behaviors of others refer to

that other people think

oneself. (The person in the

would be strange?

TV is talking to me)

Magical thinking

Confabulation

Jealousy

Religious

Executive Function

Abstract thinking

Concrete thinking

Information processing,

Fund of knowledge:

Vocabulary:

intelligence and Formal and

¡õHigh ¡õAverage ¡õLow

¡õHigh ¡õAverage ¡õLow

Informal Education

Completed: Grades 1-12

BA, MA, PHD.

Attention

Average

Distractible

Concentration*

Average

Brief

*Example count back from 100 in increments of 7 or back from 20 in increments of 3 and so forth.

Suicidal thoughts

Wanting to harm self.

Aggressive or homicidal

thoughts. Wanting to harm

others.

Thought broadcasting

Grandiosity

Thought insertion by others

No Data

Self-expression:

¡õHigh ¡õAverage ¡õLow

Informal:

Hyper vigilant

Non

Oriented to Time

Do you know the time?

Y/N

Immediate Memory: Past

few hours or minutes

Recent memory: Recent past

or day/month

Remote Memory: Childhood or

past HX

Control of Impulses.

Do you think before acting or

do you act before thinking?

History of

ORIENTATION (x3, x 4)

Oriented to Person

Oriented to Place

Do you know your name?

Do you know where you

Y/N

are? Y / N

Oriented to circumstances

Do you know why you are

here? Y / N

Average

MEMORY

Below Average

No Data

Average

Below average

No Data

Average

Below average

No Data

IMPLUSE CONTROL

Hostile- aggressive

Sexual impulses

impulses Y/ N

Y/ N

JUDGMENT/SOCIAL JUDGMENT

Average

Poor

None

Does the individual notice

proper behavior. Moral

development. Questions

such as if you found a wallet

and so forth¡­.

Good

The degree of selfawareness of oneself and

one awareness

Good. Full acceptance

and awareness of self

and responsibilities

Is the person a good self

historian?

Good

INSIGHT

Average. Some acceptance

and some denial.

RELIABILITY OF REPORT

Fair

No Data

No Data

Poor. Denial and blames other

Poor

OTHER COMMENTS

Therapist Signature:________________________________________Date:______________________________

References

Folstein M.F., Folstein, S.E., and McHugh P.R. (1975). Mini-Mental State: A practical method

for grading the state of patients for the clinician. In Journal of Psychiatric Research, 12: 189-198.

Grwoth- Marnat G. (2003). Handbook of Psychological Assessment. Hoboken, New Jersey: John

Wiley & Sons, Inc.

Rosenberg, J. (2002). Course PSY 677: Psychopathology. Encino, CA: Phillips Graduate

Institute, Clinical Doctorate Psychology Program.

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