University of Maryland



Psychological Diagnostic Assessment

(Clinician to complete this document during session.)

Patient Name: _______________________________ DOB: Age: Sex:

Evaluation Date: Start time: End time:

Referred by: PCP:

Check box if evaluation is completed through telehealth.

Reason for Referral:

History of Present Illness

Depression: M ___ S ___ I___ G ___ E ___ C ___ A ___ P ___ S ___

Anxiety:

Trauma:

Sleep:

Eating:

Other:

Duration/course:

Frequency/intensity:

Functional Impairments:

Modifying Factors:

Mental Health Treatment History

PSY diagnoses (if any):

PSY meds:

Counseling (Type, Timeline, Outcome):

PSY hospitalizations:

Medical & Surgical History

Medical History:

Surgical History:

Treatment Regimen Factors:

Social History:

Family:

Current Living Situation:

Cultural considerations:

Other (finances, legal, etc):

MENTAL STATUS EXAMINATION

1=mild, 2=moderate, 3=severe

ORIENTATION Complete

Person

Place

Time

Purpose

MMSE Score (if any):

APPEARANCE

Dress Appropriate

Disheveled/dirty

Unusual/bizarre

Seductive

Meticulous/formal

Grooming Clean

Unclean

Unkempt

Meticulous/formal

Posture Appropriate

Hunched/slumped

Rigid/tense

Atypical

EYE CONTACT Appropriate

Staring/glaring

Avoidant

Fixed

MOTOR ACTIVITY

Appropriate

Overactive

Decreased/slowed

Restlessness

Tremor/tics

Repetitive Acts

Poor Coordination

AFFECT Appropriate

Full Range: Yes No

Sad/Depressed

Blunted/Flat

Fearful/Anxious

Euphoric/Elated

Angry

Labile

DEMEANOR Appropriate

Domineering

Hostile

Withdrawn

Tearful

Demanding/Needy

Dramatic

Agitated

Suspicious/Paranoid

Impulsive

Defensive

Manipulative

Overly Cooperative

Uncooperative

SPEECH

Rate Appropriate

Accelerated/fast

Decreased/slow

Quality Appropriate

Loud

Soft

Pressured

Slurred/Stammered

Disorganized

THOUGHT PROCESS

Appropriate

Perseveration

Tangential

Loose Associations

Flight of Ideas

Thought Blocking

THOUGHT CONTENT

Risk to Self/Others None

Suicidal Ideation

Suicidal Intent/Plan

Homicidal Ideation

Homicidal Intent/Plan

Assaultive Ideas/Plan

Perception None

Hallucinations

Delusions

Depersonalization

Derealization

Lost identity/Amnesia

“Lost time”

INTELLECT ESTIMATE

Superior

Above Average

Average

Below Average

Borderline

Extremely Low

Poor Knowledge Fund

Concrete Thinking

MEMORY PROBLEMS None

Poor Concentration

Poor Immediate

Poor short-term

Poor long-term

JUDGMENT Appropriate

Lacks Social Judgment

Lacks Personal Judgment

INSIGHT Appropriate

Minimizes problems

Denies problems

Blames others

SELF CONCEPT Balanced

Unrealistically Low

Unrealistically High

Substance Use (1st Use, Last Use, Heaviest Use, Current Amt/Freq, Route, Withdrawal)

Caffeine:

Tobacco:

Alcohol:

Cannabis: Opioids:

Other:

Obligation failure ____________________________

Use when hazardous __________________________

Legal problems ______________________________

Use despite problems

Taken greater/longer than intended

Unsuccessful efforts to quit

Abstinence Attempts:

Treatment:

Diagnostic Impressions

Mental Health: _______________________________________________________________________________

_______________________________________________________________________________

Personality: _______________________________________________________________________________

Medical:

Stressors:

Suicide Risk: None Low Moderate High

Homicide Risk: None Low Moderate High

Recommendations

1. ____________________________________________________________________________________

2. ____________________________________________________________________________________

3. ____________________________________________________________________________________

Referrals

1. ____________________________________________________________________________________

2. ____________________________________________________________________________________

Info for Medical Staff:

Examiner: Date:

Supervisor (if necessary): Date:

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Notes:

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