Appearance:
___ Physically unkempt, unclean
___ Clothing disheveled, dirty
___ Clothing atypical, unusual, bizarre
___ Unusual physical characteristics
___ Casual
___ Clean
___ Attractive
___ Overweight/Underweight
Orientation:
___ Person
___ Place
___ Time
Behavior: ___________________________________________________
Perceptions:
___ Illusions
___ Auditory hallucinations
___ Visual hallucinations
___ Gustatory hallucinations
___ Olfactory hallucinations
___ Tactile hallucinations
Cognition:
Intellectual functioning
___ Impaired attention span
___ Impaired abstract thinking
___ Impaired calculation ability
___ Impaired intelligence
___ Grossly intact
___ Not assessed
Insight
___ Difficulty in acknowledging the presence of psychological problems
___ Recognizes symptoms but provides a rational explanation
___ Primarily blames others or circumstances for problems
___ Good
Judgment
___ Difficulty with daily living activities
___ Difficulty making reasonable life decisions
___ Difficulty making realistic future plans
___ Difficulty with reality testing
___ Good
Memory
___ Impaired immediate recall
___ Impaired recent memory
___ Impaired remote memory
___ Grossly intact
___ Not assessed

Attention/Concentration
___ Inattentive
___ Distractible
___ Apathetic
___ Preoccupied
Thought Content
___ Obsessions
___ Compulsions
___ Phobias
___ Derealization, depersonalization
___ Suicidal ideation
___ Homicidal ideation
___ Delusions
___ Ideas of reference
___ Persecutory
Thought Form
___ Delusions of control
___ Somatic
___ Religious
___ Grandiose
___ Erotomanic
___ Jealous
___ Bizarre
___ Mood congruent
___ Mood incongruent
___ Thought broadcasting
___ Thought insertion
___ Loose associations
___ Tangential
___ Word-salad
___ Circumstantial
___ Perseveration
___ Concrete word use
___ Over inclusive word use
Speech
___ Clang association
___ Disturbed articulation
___ Dysprosody (disturbed rhythm)
___ Nonfluency
___ Pressured
___ Poverty of content
___ Circumscriptions
___ Paraphasic language
___ Neologistic language
___ Faulty grammar
Affect (external manifestation of emotion observable by clinician):
___ Sadness
___ Elation
___ Disgust
___ Anxiety
___ Anger
___ Perplexity
___ Guilt
___ Suspicion
___ Content

Missing affects? ______________________________
Affect expressed by
___ Gestures
___ Facial expressions
___ Posture
___ Grooming
___ Reactive movements
___ Goal-directed movements
___ Tone of voice
___ Pitch of voice
___ Selection of vocabulary
___ Verbal communication
Patient regulated his/her affect predominantly by
___ Suppression
___ Repression
___ Appropriate control
___ Acting out
___ Faking
___ None of the above
Intensity of affect
___ Blunted (reduced)
___ Flat (absence or near absence)
Range of affective display
___ Labile
___ Restricted/Constricted
Congruency between affect and content of speech/ideation
___ Inappropriate
Mood (subjective background emotion from patient’s description), pervasive, sustained :
___ Dysphoric
___ Elevated
___ Euthymic
___ Expansive
___ Irritable
___ Anxious
Volition (motivation):
___ Good
___ Fair
___ Poor
___ Externalized; to please another or fulfill requirement
Defensive Functioning Scale:
High Adaptive Level
___ Anticipation
___ Affiliation
___ Altruism
___ Humor
___ Self-assertion
___ Self-observation
___ Sublimation
___ Suppression
Mental Inhibitions Level (compromise formation)
___ Displacement
___ Dissociation
___ Intellectualization

___ Isolation of affect
___ Reaction formation
___ Repression
___ Undoing
Minor Image-Distorting Level
___ Devaluation
___ Idealization
___ Omnipotence
Disavowal Level
___ Denial
___ Projection
___ Rationalization
Major Image-Distorting Level
___ Autistic fantasy
___ Projective identification
___ Splitting of self-image or image of others
Action Level
___ Acting out
___ Apathetic withdrawal
___ Help-rejecting complaining
___ Passive aggression
Level of Defensive Dysregulation
___ Delusional projection
___ Psychotic denial
___ Psychotic distortion
Object Relations Development:
Attachment
___ Strongest past attachment
___ Strongest current attachment
___ Abandonment feelings
___ Insecure attachment
___ Attachment through false self
Separation/Autonomy
___ Boundaries
___ Can access help
___ Empty
Primary narcissism ______________________________
Secondary narcissism ______________________________
___ Shame
Neurosis
___ Guilt/Conscience/Moral development
___ Id
___ Ego
___ Superego
___ Adult authority
___ Relationally interdependent
___ Ability to express thoughts, feelings and needs
Defenses
___ Denial
___ Projection
___ Projective identification
___ Idealization
___ Reaction formation
___ Substances/Addictions
___ Sublimation

___ Arts
___ Humor
___ Rationalizations
___ Blaming/Externalizing
___ Immediate discharge of affect
Additional Observations:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________