MENTAL STATUS EXAM

Date:____________ Client Name: _______________________________ Age:_____ Sex:____ Ethnicity:______

Partner Status _________ Occupation _________________ Sexual Orientation _________________

Number of children _____________________________________Living Circumstances ______________

GENERAL
Appearance
Hygiene Average Unclean Body odor – Unusual
Clothing-Grooming Average, Appropriate Unkempt, Disheveled Atypical
Physical Characteristics Weight: Average, ↑ , ↓ Health: Good, Frail Unusual
Unique marks (tattoos) Body type-build Physical Disabilities

General Behavior & Mood

Motor Activity Agitated, Fidgety Restless, Decreased, Slowed. Unusual: Tics, Tremors
Pacing, Psychomotor retardation mannerisms, gestures
Facial Expression Fear, Anxious Sadness , Depression Unusual, Atypical
Anger, Hostile Joy, Reflective Absence of feelings
Speech Volume Appropriate, Audible Soft, Mute, Loud
Speech Rate Appropriate, Controlled Rapid, Pressured, Slow Deliberate, Monotonous
Speech Quantity Appropriate, Concise Monosyllables. Minimal Detailed, Elaborate
Speech Quality Appropriate, Clear Stutters, Slurred, Mumble, Impediments – ESL
State of Consciousness Alert Lethargic, Drowsy, Stupor Unresponsive. Even to pain
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 None Auditory: Do you hear? Do Visual: Do you see?
present). Do you hear voices you follow the voices?
when no one is around Olfactory: r/o brain tumor Gustatory. Do you have No Data
or disturbance. unexplained sensations
Illusions (misperceived None Present No Data
stimulus)
Derealization: Sense of None Present No Data
detachment from one’s
world/environment.
Depersonalization: Sense of None Present No Data
detachment from one’s sense of
self. Often an experience of
anxiety.
Astereognosis Identifies by touch Does not identify object No Data
APRAXIA: Difficulty carrying out purposeful voluntary movement sequences for speech in the absence of
paralysis of the speech musculature.

THOUGHT PROCESSES
Stream of Thoughts
Productivity Average Overabundance Paucity
Spontaneous Needs prompting Mixed
Continuity Goal Directed, Logical Relevant – Irrelevant to Loose associations, Rambling
Perceptive question asked
Peseveration of thoughts Effort to go from thought to Tangential,
thought
Blocking, Vacant stare Flight of ideas Circumstantial
Language and Speech Neologisms ( makes up Word Salad (in- Clang association (meaningless
impairment: 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.
Content Of Thoughts
Preoccupation Obsessions Compulsions Phobias. Paranoia. Suicidal thoughts
Persecution Wanting to harm self.
Somatic concerns: Repetitive thoughts-worry Aggressive or homicidal
Intrusive worries about thoughts. Wanting to harm
disease or defects. others.
Thought Disturbances Delusions: false beliefs: Ideas of reference: Those Thought broadcasting
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 Grandiosity
Jealousy Religious Thought insertion by others
Executive Function Abstract thinking Concrete thinking No Data
Information processing, Fund of knowledge: Vocabulary: Self-expression:
intelligence and Formal and □High □Average □Low □High □Average □Low □High □Average □Low
Informal Education Completed: Grades 1-12 BA, MA, PHD. Informal:
Attention Average Distractible Hyper vigilant
Concentration* Average Brief Non
*Example count back from 100 in increments of 7 or back from 20 in increments of 3 and so forth.
 ORIENTATION (x3, x 4)
Oriented to Time Oriented to Person Oriented to Place Oriented to circumstances
Do you know the time? Do you know your name? Do you know where you Do you know why you are
Y/N Y/N are? Y / N here? Y / N
MEMORY
Immediate Memory: Past Average Below Average No Data
few hours or minutes
Recent memory: Recent past Average Below average No Data
or day/month
Remote Memory: Childhood or Average Below average No Data
past HX

IMPLUSE CONTROL
Control of Impulses. Hostile- aggressive Sexual impulses No Data
Do you think before acting or impulses Y/ N Y/ N
do you act before thinking?
History of

JUDGMENT/SOCIAL JUDGMENT
Does the individual notice Good Average Poor None No Data
proper behavior. Moral
development. Questions
such as if you found a wallet
and so forth….

INSIGHT
The degree of self- Good. Full acceptance Average. Some acceptance Poor. Denial and blames other
awareness of oneself and and awareness of self and some denial.
one awareness and responsibilities

RELIABILITY OF REPORT
Is the person a good self Good Fair Poor
historian?

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.