Mental Status Examination Report

I. identifying Data

Name:

Age:

Date of Birth:

Sex:

Civil Status:

Religion:

Educational Attainment:

Date of Admission:

Date of Interview:

II. Genral Obeservation

III. Summary of Findings

a. Intellectual Functioningb. Emotional Functioningc. Interpersonal Functioning

IV. Recommendation

Prepared by:

__________________________Signature Over Printed Name

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Mental Status Examination Report

I. GENERAL PRESENTATIONA. Appearance. Describe the patient’s apperance and overall physical impression.

a. Body Type □ Obeese □ Over weight □ Under Weight □ Emaciated (very thin, mukhang may malubhang

sakit)

b. Apparent Age □ Younger □ Stated Age □ Older

c. Clothes □ Undressed □ Underdressed □ Overdressed □ Bizarre □ Militaristic

□ Okay for Work □ Okay for Age □ Stylish □ Okay for Weather□ Dirty

d. Grooming □ Good □ Satisfactory □ Poor-disheveled (untidy,lacking order)□ Neglected (Body odor, halitosis- bad breath)

e. Hair □ Bizarre Style (odd: unsual, strange) □ Unnatural color □ Male- unshaven facial hair

f. Nails □ Trim □ Long □ Dirty □ Short □ Others

B. Overt Behavior. Refers to both quantitative and qualitative aspects of the patient’s motor behavior.a. Mannerism- particular way of talking or moving.

□ Toying with hair □ Tapping his/her toes □ Others. _________________

b. Tics- part of the body moves repeatedly, suddenly, and uncontrollably.□ Face □ Arms □ Hand □ Others. _________________

c. Gestures- a movement of body, especially hands and arms that shows or emphasizes an idea or a feeling.□ Present, specify. _________________ □ Absent

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d. Echopraxia- involuntary imitation of movements of others also kown as echomotism.□ Present □ Absent

e. Hyperactivity □ Yes □ No

f. Stereotyped Behavior- lacking originality or individuality, imitating the wacky neighbor or character of known personality.

g. Wringing of Hands- to squeeze or twist hand to make dry□ Present □ Absent

h. Facial Expression□ Relaxed □ Laughed □ Angry□ Tensed □ Happy □ Suspicious□ Smiled □ Sad □ Tearful when discussing

i. Eye Contact□ Good □ Brief contact quickly broken, casting only for short time□ Normal □ Avoided

C. Attitude. Description of patient’s attitude towards the examiner can be described as: cooperative, friendly, attentive, interested, frank, seductive, comtemptuous, perplexed, apathetic, hostile, playful, ingratiating, evasive, and guarded. Any number of other adjectives can be used. The level of rapport established should be recorded.

□ Cooperative □ Friendly □ Unconcerned □ Careless□ Open □ Hurried □ Polite □ Negativistic/Critical□ Thoughful □ Hostile □ Quiet □ Somewhat Shy□ Imitable □ Defensive □Motivated/Focused

II. State of Consciousness. Persons’s mind and thought awareness, attention.□ Alert And Oriented □ Sleepy □ Tired □ Uninterested□ Lethargic (slow to move or act)

III. Attention and Concentrationa. Ask client the days of the week in order beginning with Monday.

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b. Ask to client to recite the days of the week in backward order.c. Ask client the months of the months of the year in order beginning with January.d. Ask client to recite the months of the year in backward order.

□ Satisfactory (Perfect) □ Sufficient (With 3-4 Errors)□ Midly Deficient (5-6 Errors) □ Poor □ Distractible

IV. Speech. Ability to speak, communicate, or express of thoughts in spoken words.□ Understandable (could initiate and hold) □ Rapid, Loud, And Mumured□ Normal Volume □ Confident □ Dear□ Meaningful □ Hard to understand □ Unwilling to engage□ Slowing, quite, and hesitant □ Use of odd or bizarre words □ Stuttering □ Unable to comprehend □ Difficulty finding words

V. Orientation: Orientation about place, person, and time.Place: Alam mo ba kung nasaan ka? ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Bakit ka nandito? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Person: 1. Sino ang nangangalaga sa magulang?________________________________________2. Noong ikaw ay nasa bahay ninyo sino ang kasama mo?__________________________3. Sino ang kilala mong presendente ng Pilipinas? _________________________________Time: Alam mo ba kung anong oras na? ___________

Araw(day)? ___________Buwan (month)? ___________Taon (year)? ___________

VI. Mood and AffectA. Mood is defined as a persuasive and sustained emotion that mood pervasive the person’s perception of the word.

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□ Angry □ Anxious □ Calm and Composed□ Euphoric (feeling of great happiness and excitement)□ Seemed Depressed □ Bored □ Generally relaxed

B. Affect may be defined as the patient’s present emotional responsiveness, inferred from the patient’s facial expression, including the amount and the range of expressive behavior.

□ Normal rage of affect (variation in facial expression, tone of voice use of hands, and body movements.)□ Constricted Affect (range and intensity of expression are reduced.)□ Blunted affect (emotional expression is further reduced.)

C. Appropriateness of affect. The pattern of observable behaviours which is the expression of a subjectively experienced feeling state (emotion) and is variable over time in response to changing emotional states.

□ Appropriate □ Inappropriate

VII. Form of Thought/Thought Processes□ organized/clear □ concrete simplistic□ no difficulty explaining thoughts and finding words □ no indication of a formal thought disorder □ flight of ideas (speech consents and a streem of accelerated thoughts with abrupt changes from topic

to topic and no central direction.)

VIII. Thought ContentPerceptual distraction in:

□ Hallucination □ Delusion□ with history □ some history□ no history except associated with drugs□ no history, but some evidence□ Repetitive thoughts □ Phobias: specify. ____________________

IX. Ability to think abstractly Proverb:

1. What is the meaning of, “Kapag binato ka ng bato, batuhin mo ng tinapay.” _____________________________________________________________________________________________________________________

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___________________________________________________________________________________________

2. Saying: Ano ang ibig sabihin ng “Ang hindi lumingon sa pinanggalingan ay hindi makararating sa paroroonan.”______________________________________________________________________________________________________________________________________________________________________________________

3. Phrases: choose one only. “Sino ang haligi ng tahanan?” ______________________________ (sagot: tatay) “Sino ang ilaw ng tahanan?” ______________________________ (sagot: nanay) “Ano ang ibig sabihin ng pusong bato?” _____________________ (sagot: manhid, walang awa)

X. Memorya. May suliranin ka ba?

□ reported problem □ difficulty to understand □ denied problemb. May paborito ka bang pelikula/libro? Pwede mo bang ikwento sa akin?

□ could recall □ could not recall

XI. Intellectual Functioning “Anong balita mo sa Pilipinas?”

□ good (able to anticipate outcomes)□ adequate (able to use feedback to learn from mistake)□ fair (able to learn from some experiences)□ poor (diffuculty predicting result of choices)□ no answer

1. Magsabi ka ng apat na naging pangulo ng bansang Pilipina?. ________________________________________________________________________________________________________________________________________________________________________________________________________________________.

□ Complete correct answer□ Incomplete answer□ Wrong answer

2. Bakit nilalabhan ang damit? _____________________________________________________________

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______________________________________________________________________________________________________________________________________________________________________________________.

3. Ano ang pagkakaparehas ng mansanas at orange? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

4. Kung ikaw ay may singkwenta piso (50php) at bumili ka ng papel sa halagang tatlongpu’t limang piso (35php), magkano ang natira o sukli?. ___________________________________.

XII. Insight and JudgementAno ang gagawin mo paglabas mo dito? ________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________.

Interviewed by:

__________________________Signature over Printed Name

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