MENTAL STATUS CHECKLIST

Appearance and Behavior

Check if applies

1. Posture

Circle

Normal ________ Limp, rigid, ill at

ease

Therapists Comments
__________________________
__________________________
__________________________

2. Gestures

Normal ________ Agitated, tics,

twitches

__________________________
__________________________
__________________________

3. Grooming

4. Dress

5. Facial
expression

Neat __________ Well groomed,

__________________________

disheveled,

__________________________

meticulous

__________________________

Dirty, careless,

__________________________

Casual ________ inappropriate,

__________________________

Formal ________ seductive

__________________________

Appropriate ____ Poor eye contact,

__________________________

dazed, staring

__________________________
__________________________

6. Speech
a. Pace

__________________________

Normal ________ Retarded,

pressured,
blocking

b. Volume

Normal ________ Soft, very loud,

monotone

c. Form

d. Clarity

__________________________

__________________________
__________________________
__________________________

Logical ________ Illogical, rambling, __________________________

Rational _______ incoherent,
coherent

__________________________

Normal ________ Garbled, slurred

__________________________
__________________________

e. Content

Normal ________ Loose, associations, __________________________

rhyming, obscene

__________________________
Form 3.6, p. 1 of 3

Attention/Affect/Mood

1. Attention

2. Mood

3. Affect

Check if applies

Circle

Normal

_______

Short span, hyper, ____________________

Alert

_______

alert, distractible

____________________

Normal

_______

Elated, euphoric,

____________________

agitated, fearful,

____________________

hostile, sad

____________________

Inappropriate,

____________________

shallow, flat,

____________________

intense

____________________

Appropriate _______

Therapists Comments

Perception and Thought Content

Check if applies

1. Hallucination

Description

________________________________

a. Auditory

___________________ ________________________________

b. Visual

___________________ ________________________________

c. Tactile

___________________ ________________________________

d. Gustatory ___________________ ________________________________

e. Olfactory

___________________ ________________________________

2. Delusion
a. Paranoid

___________________ b. Persecutory

_________________

c. Grandiose ___________________ d. Reference

_________________

e. Control

___________________ f. Thought

_________________

g. Insertion

___________________ h. Broadcasting

_________________

i. Thought withdrawal
3. Illusions
a. Visual

___________________

b. Auditory

___________________

Form 3.6, p. 2 of 3

Describe __________________________________________________________
__________________________________________________________________
4. Other derealization
a. Phobias

__________________ b. Obsessions

c. Compulsions __________________ d. Ruminations

_________________
_________________

Describe __________________________________________________________
__________________________________________________________________
5. Suicide/homicide
Ideation

__________________ Plans ______________

Describe __________________________________________________________
__________________________________________________________________

Orientation

Oriented 3

Disoriented to:

Time __________ Place __________ Person __________

Yes ____ No ____

Judgment
Intact _____________ Impaired ___________
Describe ____________________________________________________________
_____________________________________________________________________

Concentration/Memory
1.
2.
3.
4.

Memory
Immediate recall
Reversals
Concentration

Intact _____________
Good _____________
Good _____________
Good _____________

Impaired ___________
Poor ______________
Poor ______________
Poor ______________

Abstract Ability
1. Similarities
2. Absurdities
3. Proverbs

Good
Recognized
Appropriate

Poor
Not recognized
Literal

Bizarre
Concrete

Bizarre

Insight

Good

Fair

Poor

Absent

Form 3.6, p. 3 of 3