MENTAL STATUS EXAM

Patient: [Name, age]
Date and time: [Date, start time, minutes observed]
Setting: [Outpatient, inpatient unit, emergency department, home, or video]
Examiner: [Name, credentials]
Reason for exam: [New assessment, follow-up, change in presentation, or daily review]
Last exam for comparison: [Date, or none]

APPEARANCE
Age and build: [Looks stated age, older, or younger; thin, average, or heavy build]
Dress and grooming: [Well groomed and dressed for the setting, or disheveled, unclean, or unusual for the weather]
Notable features: [Scars, injuries, tattoos, odor of alcohol, signs of self-neglect, or none]

BEHAVIOR
Attitude to examiner: [Cooperative, guarded, suspicious, hostile, withdrawn, or overfamiliar]
Eye contact: [Good, poor, fleeting, or intense]
Psychomotor activity: [Normal, slowed, or agitated, with what you saw: pacing, fidgeting, rocking]
Abnormal movements: [None, or tremor, tics, dyskinesia, posturing, or other catatonic signs]

SPEECH
Rate and amount: [Normal, slow, rapid, pressured, or poverty of speech]
Volume and tone: [Normal, soft, or loud; varied or monotone]
Articulation and fluency: [Clear and fluent, slurred, or word-finding pauses]
Ease of interruption: [Easily interrupted, or hard to interrupt]

MOOD AND AFFECT
Mood: [The patient's own words, quoted]
Affect: [Euthymic, dysphoric, anxious, irritable, or euphoric]
Range and stability: [Full, restricted, blunted, or flat; stable or labile]
Congruence: [Congruent or incongruent with the stated mood and the topic]

THOUGHT PROCESS
Form: [Linear and goal-directed, circumstantial, tangential, flight of ideas, loose associations, or thought blocking]
Example: [A short quote that shows any abnormal form]

THOUGHT CONTENT
Main themes: [Preoccupations, worries, ruminations]
Delusions: [None, or type: persecutory, grandiose, referential, somatic; how firmly held]
Obsessions and phobias: [None, or content]
Suicidal ideation: [None, passive, or active; intent, plan, preparation, access to means; time frame asked about]
Homicidal ideation: [None, or target, intent, plan, access to weapons]

PERCEPTION
Hallucinations: [None reported, or modality, content, frequency, commands]
Observed behavior: [Not responding to internal stimuli, or what you saw: pausing, glancing, muttering]
Other experiences: [Illusions, depersonalization, derealization, or none]

COGNITION
Level of consciousness: [Alert, drowsy, or fluctuating]
Orientation: [Person, place, date, situation]
Attention: [Months backward, serial 7s, or digit span, with the result]
Memory: [3-word recall at 5 minutes; recent events]
Screening score: [MoCA, Mini-Cog, or other, with score, or not done and why]

INSIGHT
Insight: [Good, partial, or poor, with the patient's own explanation of the problem]

JUDGMENT
Judgment: [Good, fair, or poor, with a recent real decision as evidence]

SUMMARY
Key findings: [The abnormal findings in one or two lines, or normal exam]
Change since last exam: [Better, worse, or unchanged, and how]
Action: [Safety steps, changes to the plan, and who was told]

Signed: [Name, credentials, date and time]