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Mental Status Examination Report
I. identifyingData
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 Functioning
b. Emotional Functioning
c. Interpersonal Functioning
IV. Recommendation
Preparedby:
__________________________
Signature OverPrintedName

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Mental Status Examination Report
I. GENERAL PRESENTATION
A. Appearance.Describe the patient’sapperance and overallphysical impression.
a. BodyType □ Obeese □ Overweight □ Under Weight □ Emaciated(verythin,mukhangmay
malubhangsakit)
b. ApparentAge □ Younger □ StatedAge □ Older
c. Clothes □ Undressed □ Underdressed □ Overdressed □ Bizarre □ Militaristic
□ Okay forWork □ Okay forAge □ Stylish □ Okay forWeather
□ Dirty
d. Grooming □ Good □ Satisfactory □ Poor-disheveled(untidy,lackingorder)
□ Neglected(Bodyodor,halitosis- badbreath)
e. Hair □ Bizarre Style (odd:unsual,strange) □ Unnatural color □ Male- unshavenfacial hair
f. Nails □ Trim □ Long □ Dirty □ Short □ Others
B. Overt Behavior. Referstobothquantitative andqualitative aspectsof the patient’smotorbehavior.
a. Mannerism- particularwayof talkingor moving.
□ Toyingwithhair □ Tappinghis/hertoes □ Others._________________
b. Tics- part of the bodymovesrepeatedly,suddenly,anduncontrollably.
□ Face □ Arms □ Hand □ Others._________________
c. Gestures- amovementof body,especiallyhandsandarmsthat shows or emphasizesanideaora feeling.
□ Present,specify._________________ □ Absent
d. Echopraxia- involuntaryimitationof movementsof othersalsokownasechomotism.
□ Present □ Absent

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e. Hyperactivity □ Yes □ No
f. StereotypedBehavior- lackingoriginalityorindividuality,imitatingthe wackyneighbororcharacter of knownpersonality.
g. Wringingof Hands- to squeeze ortwisthandto make dry
□ Present □ Absent
h. Facial Expression
□ Relaxed □ Laughed □ Angry
□ Tensed □ Happy □ Suspicious
□ Smiled □ Sad □ Tearful when discussing
i. Eye Contact
□ Good □ Brief contact quicklybroken,castingonlyforshorttime
□ Normal □ Avoided
C. Attitude.Descriptionof patient’sattitude towardsthe examinercanbe describedas:cooperative,friendly,attentive,interested,
frank,seductive,comtemptuous,perplexed,apathetic,hostile, playful,ingratiating,evasive,andguarded.Anynumberof other
adjectivescanbe used.The level of rapportestablishedshouldbe recorded.
□ Cooperative □ Friendly □ Unconcerned □ Careless
□ Open □ Hurried □ Polite □ Negativistic/Critical
□ Thoughful □ Hostile □ Quiet □ SomewhatShy
□ Imitable □ Defensive □Motivated/Focused
II. State of Consciousness.Persons’s mindandthoughtawareness,attention.
□ AlertAndOriented □ Sleepy □ Tired □ Uninterested
□ Lethargic(slowtomove or act)
III. Attentionand Concentration
a. Askclientthe daysof the weekinorderbeginningwithMonday.
b. Askto clienttorecite the days of the weekinbackwardorder.
c. Askclientthe monthsof the monthsof the yearin orderbeginningwithJanuary.

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d. Askclienttorecite the monthsof the yearin backwardorder.
□ Satisfactory(Perfect) □ Sufficient(With3-4Errors)
□ MidlyDeficient(5-6Errors) □ Poor □ Distractible
IV. Speech.Abilitytospeak,communicate,orexpressof thoughtsinspokenwords.
□ Understandable (couldinitiate andhold) □ Rapid, Loud,And Mumured
□ Normal Volume □ Confident □ Dear
□ Meaningful □ Hard to understand □ Unwillingtoengage
□ Slowing,quite,andhesitant □ Use of odd or bizarre words
□ Stuttering □ Unable to comprehend □ Difficultyfindingwords
V. Orientation: Orientationaboutplace,person,andtime.
Place:Alammo bakungnasaanka? _____________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Bakit kanandito? ___________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Person:
1. Sino angnangangalagasamagulang?________________________________________
2. Noongikaway nasabahay ninyo sino angkasama mo?__________________________
3. Sinoang kilalamongpresendente ngPilipinas?_________________________________
Time: Alammo bakunganongorasna? ___________
Araw(day)? ___________
Buwan(month)?___________
Taon(year)? ___________
VI. Mood and Affect
A. Mood isdefinedasa persuasiveandsustainedemotionthatmoodpervasive the person’sperceptionof the word.
□ Angry □ Anxious □ Calmand Composed
□ Euphoric(feelingof greathappinessandexcitement)

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□ SeemedDepressed □ Bored □ Generallyrelaxed
B. Affectmay be definedasthe patient’spresentemotionalresponsiveness,inferredfromthe patient’sfacial expression,including
the amountand the range of expressivebehavior.
□ Normal rage of affect(variationinfacial expression,tone of voice use of hands,andbodymovements.)
□ ConstrictedAffect(range andintensityof expressionare reduced.)
□ Bluntedaffect(emotional expressionisfurtherreduced.)
C. Appropriatenessofaffect. The patternof observable behaviourswhichisthe expressionof asubjectivelyexperiencedfeeling
state (emotion) andisvariable overtime inresponse tochangingemotional states.
□ Appropriate □ Inappropriate
VII. Form of Thought/Thought Processes
□ organized/clear □ concrete simplistic
□ no difficultyexplainingthoughtsandfindingwords
□ no indicationof aformal thoughtdisorder
□ flightof ideas(speechconsentsand a streemof acceleratedthoughtswithabruptchangesfromtopic
to topicand no central direction.)
VIII. Thought Content
Perceptual distractionin:
□ Hallucination □ Delusion
□ withhistory □ some history
□ no historyexceptassociatedwithdrugs
□ no history,butsome evidence
□ Repetitivethoughts □ Phobias:specify.____________________
IX. Abilityto think abstractly
Proverb:
1. What isthe meaningof,“Kapagbinatokangbato,batuhin mo ngtinapay.”__________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

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2. Saying:Ano angibig sabihinng“Anghindi lumingonsapinanggalinganay hindimakararatingsaparoroonan.”
___________________________________________________________________________________________
___________________________________________________________________________________________
3. Phrases:choose one only.
 “Sino anghaligi ngtahanan?”______________________________ (sagot:tatay)
 “Sino angilaw ngtahanan?”______________________________ (sagot:nanay)
 “Ano angibig sabihinngpusongbato?”_____________________ (sagot:manhid,walangawa)
X. Memory
a. May suliraninka ba?
□ reportedproblem □ difficultytounderstand □ deniedproblem
b. May paboritokabangpelikula/libro?Pwedemo bangikwentosa akin?
□ couldrecall □ couldnot recall
XI. Intellectual Functioning
“Anongbalitamo sa Pilipinas?”
□ good (able toanticipate outcomes)
□ adequate (able touse feedbacktolearnfrommistake)
□ fair(able to learnfromsome experiences)
□ poor (diffucultypredictingresultof choices)
□ no answer
1. Magsabikangapatnanagingpangulo ngbansangPilipina?.__________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________.
□ Complete correctanswer
□ Incomplete answer
□ Wrong answer
2. Bakit nilalabhanangdamit? _____________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________.

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3. Ano angpagkakaparehasngmansanasatorange?___________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________.
4. Kungikaway may singkwentapiso (50php) atbumili ka ngpapelsa halagangtatlongpu’tlimangpiso (35php),magkano ang
natirao sukli?. ___________________________________.
XII. Insightand Judgement
Ano anggagawinmo paglabasmo dito? ________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________.
Interviewedby:
__________________________
Signature overPrintedName