Patient’s Name:_______________________________________________
Date:_________________
Category
Appearance
Descriptors
Grooming, hygiene, dress, appears stated age?, posture, weight
Behavior
Motor: agitation vs. retardation; lethargy, restlessness, tics, tremors,
mannerisms, dyskinesias, negativism, waxy flexibility, gait
Attitude toward interviewer: cooperative, hostile, contemptuous,
submissive, fearful, provocative, suspicious
 Volume
 Rate
 Tone (accent, slurred)
 Rhythm / prosody
 Pressure
 Fluency (stuttering, spontaneous, monosyllabic)
 Neologisms (words known only to the patient)
 Idiosyncratic
Mood: underlying pervasive feeling state – determined by asking the
patient and/or by observing his or her predominant expression
 Depressed
 Euphoric
 Elated
 Euthymic
 Irritable
 Anxious
 Fearful
 Gloomy
 Tense
 Apathetic
Affect: observed emotional responses in the interview – assess
appropriateness and congruence with mood, and range (full, flat,
restricted) and reactivity
Hallucinations: visual, auditory; tactile, olfactory, gustatory; content,
congruence with mood and with thought content
Other: depersonalization, derealization, déjà vu, jamais vu, macropsia
(objects appear larger than they really are), illusions (perceptions
derived from a misinterpretations of actual sensory input)
Delusions: persecutory (paranoid), grandiose, infidelity, somatic,
thought broadcasting, thought withdrawal, thought insertion, ideas of
reference; descriptors may include bizarre, organized, elaborate
Other: phobias, hypochondriasis, obsessions/compulsions,
preoccupations
Suicidal ideation: passive or active, plan, access to means, intent,
deterrents
Homicidal ideation: intent, plan (if so, duty to warn must be in plan)
Associations: goal-directed, loose, illogical, word salad, circumstantial,
tangential, thought blocking, flight of ideas, idiosyncratic speech,
preservation
Sensorium: level of consciousness (alert, stuporous, obtunded,
comatose)
Orientation: to person, place, time
Memory: remote (historical questions), recent (last meal, how got to this
appointment), short-term (three objects after 5 minutes)
Attention: serial 7’s, “world” forward and backward
Information and Intelligence: use of vocabulary, fund of knowledge
(current governor, presidents), level of education
Abstraction: interpretations of proverbs, similarities
Language: naming, writing, understanding commands
Visuospacial function: clock drawing, intersecting pentagons
Best answered in the course of the interview; otherwise, stamped letter
or fire question
Insight into illness: recognizing illness and need for treatment (good, fair,
poor)
Speech
Mood & Affect
Perception
Thought
content
Thought
process
Cognition
Judgment
Insight
Observations