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Mental Status Exam Template

1. This document provides a template for conducting a mental status exam, which assesses general appearance and behavior, mood and affect, speech, thought processes, sensorium and cognition, perceptual disturbances, and insight and judgment. 2. The template includes guidelines for evaluating factors like appearance, hygiene, behavior, mood, affect, speech patterns, thought processes, orientation, attention, memory, abstract thinking, hallucinations, and insight. 3. Specific criteria are provided to describe observations for each factor, such as rate and content of speech, thought organization and content, level of consciousness, and quality of insight.

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284 views2 pages

Mental Status Exam Template

1. This document provides a template for conducting a mental status exam, which assesses general appearance and behavior, mood and affect, speech, thought processes, sensorium and cognition, perceptual disturbances, and insight and judgment. 2. The template includes guidelines for evaluating factors like appearance, hygiene, behavior, mood, affect, speech patterns, thought processes, orientation, attention, memory, abstract thinking, hallucinations, and insight. 3. Specific criteria are provided to describe observations for each factor, such as rate and content of speech, thought organization and content, level of consciousness, and quality of insight.

Uploaded by

Nicholas
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Mental status exam template.

1. General appearance and behavior


(a) Appearance
Estimated age: 20s/30s/40s/50s etc…; (doesn’t) appears his age.
Body habitus: endomorph/mesomorph/ectomorph/obese/underweight/marfanoid
Posture: seated/lying; upright/slouching; open/closed; tensed/relaxed;
Hygiene: Clothes: unkempt/kempt; hospital uniform/no hospital uniform; distinguishing features
Body odor: yes/no; halitosis; yes/no
Dress: appropriate/inappropriate (seductive, excessive make-up, flamboyant clothing)
(b) Behavior
Eye contact: maintains/doesn’t maintain; fleeting/ intrusive
Rapport: easily established/not easily established; maintained/not maintained
Attitude: friendly/hostile/evasive/co-operative/secretive/apathetic/focused/easily distracted
Level of distress: no distress/ distress because of pain/psychomotor agitation/glancing repeatedly at
different parts of room/.

(c) Abnormal motor activity


Disinhibition/mannerisms/tics/stereotypy/restless/abulia/apraxia

2. Mood and Affect


(a) Affect; Quality: dysphoric/neutral/euphopric/euthymic/detached/anxious/irritable/sad/angry,elated

Congruence: congruent/incongruent for mood.


Range: broad/restricted; flat/blunted; full/exaggerated; labile/fixed
(b) Mood: sad/happy/guilty/exhausted/frustrated/frightened/indifferent/marvelous/embarrassed

3. Speech
Rate: rapid/normal/slow/pressured/poverty of speech
Volume: loud/normal/soft/ whispered
Articulation:
incomprehensible/accented/shuttered/lisping/mumbled/slurred/clear/fluent/neologisms/echolalia/dys
arthia/mutism

4. Thought evaluation
(a) Process: circumstantiality/tangentially/loose associations/flight of ideas/clang
associations/perseveration/thought blocking
(b) Content: specific delusions/phobias/suicidal or homicidal ideation/ obsessions and pre-occupations

5. Sensorium and cognition


(a) Orientation: oriented in time, place and person.
(b) Level of consciousness: alert/drowsy/lethargic/obtunded/stupor/comatose/delirious
(c) Attention and concentration: intact/impaired; serial 5 or 7 subtraction from 100
(d) Memory; Immediate: intact/impaired. (retrograde/anterograde/ global amnesia)
Short term: intact/impaired (retrograde/anterograde/global amnesia)
Long term: intact/impaired.(retrograde/anterograde/global amnesia) confabulation
(e) Fund of knowledge: adequate/inadequate for level of education.
(f) Abstract thinking: proverb/similarities testing; Intact/impaired;

6. Perceptual disturbances
specific hallucinations/illusions/dissociations/agnosia/hemi-neglect
7. Insight and judgement
(a) Insight: Grade1,2,3 or 4/anosognosia.
(b) Judgement: Test judgement/personal judgement intact/ impaired

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