Mental Status Exam (WNL = Within Normal Limits) ( ) If Checked, Risk Assessment Is Required

Mental Health Status Exam

Person’s Name (First MI Last): Record #: Date of Admission: Organization/Program Name: DOB: Gender: Male Female Transgender

Mental Status Exam – (WNL = Within Normal Limits) (**) – If Checked, Risk Assessment is Required Appearance/ Disheveled Out of the WNL Neat and appropriate Physically unkempt Clothing: Ordinary Eye Contact: WNL Avoidant Intense Intermittent Build: WNL Thin Overweight Short Tall Posture: WNL Slumped Rigid, Tense Atypical Body Movement: WNL Accelerated Slowed Peculiar Restless Agitated WNL Cooperative Uncooperative Overly Compliant Withdrawn Sleepy Silly Avoidant/Guarded/ Nervous/ Anxious Preoccupied Restless Demanding Suspicious Behavior: Controlling Unable to perceive Provocative Hyperactive Impulsive Agitated pleasure Angry Assaultive Aggressive Compulsive Relaxed WNL Mute Over-talkative Slowed Slurred Stammering Speech: Rapid Pressured Loud Soft Clear Repetitive Emotional State- WNL Not feeling anything Irritated Happy Angry Hostile Mood (in Depressed, Anxious Afraid, person’s words): sad Apprehensive Emotional State- WNL Constricted Changeable Inappropriate Flat Affect Full Blunted, unvarying WNL Anxiety, fear, Sadness, depression Anger, hostility, Facial Expression apprehension irritability Elated Expressionless Inappropriate Unvarying Perception: WNL Hallucinations- Tactile Auditory Visual Olfactory Command ** Thought Content: WNL None Reported Grandiose Persecutory Somatic Illogical Chaotic Delusions- Religious Preoccupied Obsessional Guarded Phobic Suspicious Guilty Other Content- Thought Thought insertion Ideas of reference broadcasting Flight of WNL Incoherent Decreased thought Blocked Thought Process: flow ideas Loose Racing Chaotic Concrete Tangential

Intellectual Lessened fund of Impaired Impaired calculation Functioning: WNL common concentration ability knowledge Intelligence Develop. No formal Borderline Average Above average Estimate - Disabled testing Orientation: WNL Disoriented to: Time Place Person Remote Short Attention Memory: WNL Impaired: Immediate recall Recent memory memory Span Difficulty acknowledging presence of Mostly blames other Insight: WNL Thinks he/she has no problems psychological problems for problems Impaired Ability to Make Judgment: WNL Mild Moderate Severe** Reasonable Decisions: Past Attempts to Harm Self or None Reported Self** Others** Others: None Self Abuse Cutting** Burning** Other: Thoughts: reported None Suicidal Passive SI** Intent** Plan** Means** Thoughts: reported None Aggressive Intent** Plan** Means** Thoughts: reported

Review Date: 4-30-13 Mental Health Status Exam

Comments:

2 Mental Health Status Exam

Person’s Name (First MI Last): Record #: Person’s Signature (Optional, if clinically Date: Parent/Guardian Signature (If appropriate): Date: appropriate)

Clinician/Provider - Print Name/Credential: Date: Supervisor - Print Name/Credential (if Date: needed):

Clinician/Provider Signature: Date: Supervisor Signature (if needed): Date:

Psychiatrist/MD/DO (If required): Date:

Review Date: 4-30-13