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Name/rank/ ssn : CC: HPI: Sleep: Interest: Guilt:

Allergies: Family Psychiatric and Medical History: Developmental/Social History: Childhood history (how was patient raised): H/o Trauma: Marrital Status Sexual History: VITALS MENTAL STATUS EXAM

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Name/rank/ ssn : CC: HPI: Sleep: Interest: Guilt:

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  1. Allergies: Family Psychiatric and Medical History: Developmental/Social History: Childhood history (how was patient raised): H/o Trauma: Marrital Status Sexual History: VITALS MENTAL STATUS EXAM APPEARANCE: hygeine / neat appearance / disheveled / for age BEHAVIOR: (un)cooperative / engaging / hostile / eye contact / agitated SPEECH: unremarkable / mute /slowed /fast / pressured / slurred / incoherent MOOD: Euthymic/ euphoric / cheerful / apathetic / irritable / angry / depressed / anxious AFFECT: (in)congruent / incongruent / full / constricted / blunted / labile TP: logical / concrete / blocking / goal directed / tangential / circumstantial / flight of ideas / perseveration / disorganized TC: SI/HI / delusions / ideas of reference /preoccupied / unremarkable PERCEPTION: normal vs hallucinatory COGNITION: MMSE (see reverse) INTELLIGENCE: above average / average / below average. INSIGHT: Complete / Partial / Nill JUDGMENT: good / fair / poor Name/rank/ssn: CC: HPI: Sleep: Interest: Guilt: Energy: Concentration: Appetite/Weight: Psychomotor Hallucinations: Delusions: Positive Sx of Schizophrenia: Suicidal/Homicidal Ideations: Past Psychiatric History: Alcohol history/tobacco: Recrational drugs: Military/Occupational History: PMH/PSH:. MEDS/OTCs: Distractable: Irresponsible: Grandiose: Flight of Ideas: Activity (goals): Sleep deprived: Talkative:

  2. Mini-mental Status Exam: 5 (What time is it—year, season, month, day, date) (Where are we—state, county, town, hospital, floor) Guitar, Chemistry, Book – Immediate recall Serial 7s (100, 93, 86, 79, 72, 65) Repeat above 3 objects Name a pencil , name a watch Repeat “No ifs and or butts” 3-step command: Take this paper in your right hand, fold it in half, place it on the floor Read and obey the following: “Close your eyes” 1 Write a sentence 1 Copy a desin Differential Diagnosis with Multiaxial Diagnosis: Axis I: Axis II: Axis III: Axis IV: Axis V: Problem List and Treatment Plan:

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