STUDENT/COURSE: ________________________________________________________________________________________________________
DEMOGRAPHICS: Patient’s Age: _______________________ Patient’s Gender: __________________
Date of this Admission: ___________________________ HT: _____________ in. WT _____________ lb. / kg
Allergies: NKDA Other _______________________________________________________________________________________
Psychosocial and Environmental Problems:
Primary support group: Social environment:
Educational: Occupational:
Housing: Economic:
Access to health care services: Interaction with the legal system/crime
Mental Health Diagnosis:
Brief Admission History (What led to your patient needing psychiatric hospitalization?):
Describe any Family History of Psychiatric Issues if available:
Describe any Substance History if available:
Describe any Trauma History if available: (Domestic Violence, sexual or physical abuse, etc.)
, STUDENT/COURSE: _____________________________________________________________________________________________________
MENTAL STATUS EXAMINATION (MSE)
ASSESSMENT OF CLIENT MENTAL STATUS: OBJECTIVE AND SUBJECTIVE DATA
YOUR ASSESSMENT AFTER INTERACTING WITH THE CLIENT
Describe General Appearance: (select all that apply)
Eye Contact: Dress: Build:
Absent Conservative Thin
Avoided Non-conservative Medium
Intermittent Appropriate Heavy
Direct Inappropriate Very Obese
Physical Handicaps Other: Other: _______________________
Posture: Gait: Hygiene: Facial Expression:
Appropriate Steady Clean Calm Happy
Slumped Ataxic Unkempt Vacant Hostile
Rigid Slow Neat Mask-like Sad
Other: _______________________ Rapid Unshaven Worried
Odorous Other: ________________
Activity: Response to examiner:
Hyperactive Defensive
Hypoactive Trusting
Restless Cooperative
Normal Indifferent
Other: Other:
Notes Regarding General Appearance:
Describe Behavior, Mood and Affect:
BEHAVIOR: (select all that apply)
Cooperative Uncooperative Non-adherent Compulsions Posturing
Restless Agitated Relaxed Tearful Manipulative
Withdrawn Catatonic Seductive Lethargic
Other:
MOOD: (select all that apply)
Dysthymic Happy Elated Angry Calm Suspicious Anxious
Ashamed Frightened Consistent with thoughts Inconsistent with thoughts
Other: ___________________________________________________________________________________________
AFFECT: (select all that apply)
Flat Blunted Labile Bright Fearful Euphoric Congruent Limited Range Full Range
Intense
Other:
Notes Regarding Behavior, Mood and Affect:
DEMOGRAPHICS: Patient’s Age: _______________________ Patient’s Gender: __________________
Date of this Admission: ___________________________ HT: _____________ in. WT _____________ lb. / kg
Allergies: NKDA Other _______________________________________________________________________________________
Psychosocial and Environmental Problems:
Primary support group: Social environment:
Educational: Occupational:
Housing: Economic:
Access to health care services: Interaction with the legal system/crime
Mental Health Diagnosis:
Brief Admission History (What led to your patient needing psychiatric hospitalization?):
Describe any Family History of Psychiatric Issues if available:
Describe any Substance History if available:
Describe any Trauma History if available: (Domestic Violence, sexual or physical abuse, etc.)
, STUDENT/COURSE: _____________________________________________________________________________________________________
MENTAL STATUS EXAMINATION (MSE)
ASSESSMENT OF CLIENT MENTAL STATUS: OBJECTIVE AND SUBJECTIVE DATA
YOUR ASSESSMENT AFTER INTERACTING WITH THE CLIENT
Describe General Appearance: (select all that apply)
Eye Contact: Dress: Build:
Absent Conservative Thin
Avoided Non-conservative Medium
Intermittent Appropriate Heavy
Direct Inappropriate Very Obese
Physical Handicaps Other: Other: _______________________
Posture: Gait: Hygiene: Facial Expression:
Appropriate Steady Clean Calm Happy
Slumped Ataxic Unkempt Vacant Hostile
Rigid Slow Neat Mask-like Sad
Other: _______________________ Rapid Unshaven Worried
Odorous Other: ________________
Activity: Response to examiner:
Hyperactive Defensive
Hypoactive Trusting
Restless Cooperative
Normal Indifferent
Other: Other:
Notes Regarding General Appearance:
Describe Behavior, Mood and Affect:
BEHAVIOR: (select all that apply)
Cooperative Uncooperative Non-adherent Compulsions Posturing
Restless Agitated Relaxed Tearful Manipulative
Withdrawn Catatonic Seductive Lethargic
Other:
MOOD: (select all that apply)
Dysthymic Happy Elated Angry Calm Suspicious Anxious
Ashamed Frightened Consistent with thoughts Inconsistent with thoughts
Other: ___________________________________________________________________________________________
AFFECT: (select all that apply)
Flat Blunted Labile Bright Fearful Euphoric Congruent Limited Range Full Range
Intense
Other:
Notes Regarding Behavior, Mood and Affect:
