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MentalHealthExaminationForm 2 2 2 2 2 2 2 2 2

Mental Health Examination
Patient’s Name:
Date of Evaluation:
Referral Source:
A. Reason for referral
B. Psychiatric history (past hospitalizations, interventions):
C. General Description of patient:
1. Appearance
2. Behavior/Psychomotor Activity:
3. Attitude towards examiner:
4. Speech
D. Orientation:
E. Mood and Affect:
1. Mood
2. Affective Expression
F. Perceptual Disturbances
1. Hallucinations
G. Thought Process:
1. Thought Disorder
2. Content of Thought
3. Assessment of suicide/homicidal risk
4. Cognitive functioning
i. Level of intelligence
ii. Ability to Abstract
iii. Concentration/Attention
H. Memory:
1. Remote
2. Immediate Recall
3. Recent
I. Impulse Control (control over hostile, aggressive, or sexual impulses, compulsive or
addictive behaviors – include drug overdoses):
J. Judgement (Understanding social situations, and knowledge of appropriate reactions, ability
to plan realistically):
K. Insight (Awareness of illness, ability to see cause and effect, use of denial or projection –
degree of insight):
L. Current psychotropic medication (dosage and times):
M. Diagnostic impression:
a. Domain 1
b. Domain 2
Prognosis – Describe: