Mental Status Exam Revision Date: 1-17-13 Page |1 Organization Name: Program Name: Individual’s Name (First MI Last): Date: Record #: DOB: MENTAL STATUS EXAM (MSE) General Observations Appearance WNL Other: Well Groomed Unkempt Disheveled Build/Stature WNL Thin Overweight Short Posture WNL Slumped Rigid Tense Eye Contact Average Avoidant Intense Intermittent Comment/Other: Activity WNL Attitude Toward Examiner Cooperative Seductive Ingratiating Accelerated Atypical Defensive Demanding Comment/Other: Demanding Depressed Anxious Angry Euphoric Affect - Full Comment/Other: Constricted Flat Inappropriate Labile Speech - Loud Rapid Pressured Agitated Comment/Other: Anxious Immature Lack of spontaneity Cannot separate Mood - Euthymic Comment/Other: Slurred Impulsive Evasive Manipulative Separation (for Children/Adolescent) Not Applicable Unremarkable/age appropriate Clingy to parent/guardian, but separates Disinhibited/does not care Comment/Other: Clear Irritable Overproductive Silly Underproductive Echolalic Comment/Other: Thought Process Incoherent Comment/Other: Perception Logical Concrete WNL Hallucinations Auditory Circumstantial Blocked Illusions Tangential Flight of Ideas Depersonalization Command Visual Loose Poverty of Content Racing Slowed Thinking Derealization Reexperiencing Olfactory Tactile Gustatory Comment/Other: Thought Content WNL Preoccupations/Ruminations Grandiose Delusions None reported Persecution Phobic Control Reference - Obsessional Thought Withdrawal Grandeur Somatic None Reported or Observed OR: Danger To: Self: Plan Intent Depressive Paranoid Self-Deprecatory Comment/Other: Risk Assessment Ideation Attempt / Others: Thought Insertion Thought Broadcasting Religious Comment/Other: Ideation Plan Intent Erotic Attempt Comments: Cognition WNL OR Check all that apply below Impairment of: Orientation Visuospatial ability Memory Reading and Writing Comment/ Comment/Other: Stereotyped/Peculiar Attitude Toward Parent/Guardian: Not Applicable Positive interaction Ignores Parents Disrespectful Comment/Other: Soft Appears older than age Tall Comment/Other: Slowed Hostile Mistrustful Confused Appears younger than age Attention/Concentration Calculation Ability Ability to Abstract Fund of Knowledge Mental Status Exam Revision Date: 1-17-13 Page |2 Intelligence Estimate Insight WNL Judgment WNL MR Borderline Average Mostly blames others for problems Above Average Difficulty acknowledging presence of psychiatric problems Impaired ability to make reasonable decisions: Mild Moderate Severe Elaboration on Positive Mental Status Findings: Completed By - Print Name/Credentials: Staff Signature: Date:
