Académique Documents
Professionnel Documents
Culture Documents
CONDITIONS OF ADMISSION
I. PRESENTING PROBLEM
A. Statement in the client’s own words of why he or she is hospitalized or
seeking help
B. Recent difficulties/alterations in
1. Relationships
2. Usual level of functioning
3. Behavior
4. Perceptions or cognitive abilities
C. Increased feelings of
1. Depression
2. Anxiety
3. Hopelessness
4. Being overwhelmed
5. Suspicious
6. Confusion
D. Somatic changes, such as
1. Constipation
2. Insomnia
3. Lethargy
4. Weight loss or gain
5. Palpitations
V. CULTURAL INFLUENCES
A With what cultural group do you identify? _______________________________
Have you tried any cultural remedies or practices for your condition? If so, what?
________________________________________________________________
C. Do you use any alternative or complimentary medicines/herbs/practices?
________________________________________________________________
MENTAL STATUS EXAMINATION
General Appearance Day
1 2 3 4 5
Facial Expression
Animated
Fixed or Immobile
Sad or Depressed
Angry
Pale
Reddened
Posture
Slouched
Stooped
Upright (erect)
Stiff
Gait
Smooth Rhythmic
Shuffling
Staggering
Dress
Appropriately Dressed
Inappropriately Dressed
Pressed
Wrinkled
Grooming
Well Groomed
Unkempt
Hygiene
Clean
Untidy
Odor (Body / Breath)
None
Alcohol
Acetone
Pungent
Cigarette Smoke
Foul Smelling
Physical Deformity:
(specify)_____________________
Eye Contact
Maintains Good Eye Contact
Poor Eye Contact (Lacks Eye Contact)
3
Eye Cast (Client squints his eyes, pupils
dilated)
MOTOR BEHAVIOR
Gestures, stereotyped behavior, pacing, any
purposeless activity should be described.
Purposeful and Coordinated Movement
Catatonia
Echopraxia
Tics
Spasm
Compulsive
Waxy Flexibility
Parkinson-like symptoms
Akathisia
Dyskinesia
Apraxia
Catatonic Stupor
Catatonic Excitement
Hyperkinesia
Catalepsy
Cataplexy
Speech
How the client is communicating, rather than
what the client is telling you. Rate, volume,
modulation and flow.
Rate
Rapid
Slow
Volume
Loud
Soft/mumbled
Quantity
Paucity
Muteness
Voluminous
Quality
Articulate
Congruent
Spontaneous
Monotonous
Talkative
Repetitious
Pressured Speech
Emotional State (Mood/Affect)
Expression of emotion as seen by
others;what examiner infers from
patient’s facial expression/behavior
Appropriate
Inappropriate
Flat
Pleasurable Affect
Euphoria
Exaltation
Ecstacy
Unpleasurable
4
Depression
Anxiety
Fear
Agitation
Ambivalence
Aggression
Mood Swings
Lability
Panic
Anger
Perceptions
Process by which physical stimuli are
brought to mental awareness
Hallucinations
Auditory
Visual
Tactile
Gustatory
Olfactory
Illusions
Depersonalization
Derealization
Thinking
The waythe person functttions
intellectually; the process or way of
thinking or analysis of the world: the
way of connecting or associating
thoughts; the overall organization of
thoughts.
1.1 Delusions
a. Delusions of Grandeur
b. Delusions of Reference
c. Delusions of Persecution
d. Religious Delusion
e. Somatic Delusion
f. Paranoid Delusion
1.2 Phobia: Specify
_________________________
5
.i Confabulation
.j Word Salad