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 (Angry/hostile, uncooperative, withdrawn, inappropriate, fearful, hypervigilant)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?