BRIEF MENTAL STATUS EXAM

Name of Patient:______________________________________ Brgy/Sitio:_______________

Name of Caregiver:____________________________________ Relation to Pt:____________

1 Appearance Normal Grooming Abnormal, describe:

2 Attitude Calm & Cooperative Other, describe:

3 Behavior No unusual movements Other, describe:

4 Speech Rate: Fast Normal Non-responsive

Volume: Loud Normal Soft

Patterns: Coherent Flight of Ideas Other, describe:

5 Affect Normal HyperReactive Depressed Flat

Tearful Other, describe:

6 Mood Normal Irritable Anxious Depressed Elevated

Other, describe:

7 Thought Process Logical Disorganized Other, describe:

8 Thought Content Delusions Obsessions/Compulsions Phobias

Suicidal Ideation: Yes No

Homicidal Ideation: Yes No

Other, describe:

9 Perception Hallucinations

Other, describe:

10 Orientation Oriented to Time: Yes No

Oriented to Place: Yes No

Oriented to Person: Yes No

11 Memory Intact Not Intact

12 Insight/Judgment Good Fair Poor

Person Administering Exam:_______________________________________ Date:___________