Appendix F: Mental state examination

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Name_______________________________________D.O.B.______________________ Date_________________


Appearance

Physical appearance? (posture, grooming, clothing, signs of AOD use, nutritional status)

 

 

 

Behaviour

General behaviour? Behaviour to situation and to examiner? (angry/hostile, unco-operative, withdrawn,
inappropriate, fearful, hypervigilant)

 

 

 

Speech

Rate, volume, tone, quality and quantity of speech?

 

 

 

Language (form of thought)

Incoherence/illogical/irrelevant thinking? Amount? Rate?

 

 

 

Mood and affect

How does the client describe his/her emotional state (mood)? What do you observe about the person’s
emotional state (affect)? Are these two consistent and appropriate?

 

 


Thought content

Delusions, suicidality, paranoia, homicidality, depressed/anxious thoughts?

 

 

 

Perception

Hallucinations? Depersonalisation? Derealisation?

 

 


Cognition

Level of consciousness? Attention? Memory? Orientation? Abstract thoughts? Concentration?

 

 

 

Insight and judgement

Awareness? Decision making?