Mental Health Assessment

Question 0

Appearance

Answer 0

Posture - erect and position
Body Movements
Dress
Grooming and Hygiene

Question 1

Mental Status

Answer 1

Appearance
Behaviour
Cognition
Thinking

Question 2

Behaviour

Answer 2

Level of conscious

Mood and affect

Speech - smooth, clear, not choppy or muffled. Easily makes laryngeal sounds

Facial expression

Question 3

Cognition

Answer 3

Orientation - to time, to place, to person and to self
Memory - immediate, recent, remote
Attention
New learning - four unrelated word test
Insight - into ones own illness/need for treatment
Judgement - plans for future

Question 4

Thinking

Answer 4

Thought Processes
Thought Content
Perceptions

Question 5

Thought Processes

Answer 5

Does this person make sense?

Can I follow what they are saying?

Do they deviate from topic more than once?

Is the way they think logical, coherent, goal direct, relevant and consistent with reality?

Question 6

Thought Content

Answer 6

Should be consistent and logical

Ask questions to uncover compulsions - do you count things over and over or perform specific actions to reduce stress

Fears: do you have any fears that cause you to avoid certain situations?

Delusions: do you have any thoughts other people think are strange
Do you have any special powers or abilities?

Question 7

Perceptions

Answer 7

Should be consistently aware of reality and perceptions should be congruent with yours

How do people treat you?
Do you feel as if you are being watched, followed, or controlled?

Is your imagination very active?

Have you heard your name when you are alone?

Question 8

Posture

Answer 8

Is erect and position is relaxed

Question 9

Body Movements

Answer 9

Are voluntary, deliberate, coordinated, smooth and even

Question 10

Dress

Answer 10

Is appropriate for setting, season, age, gender, and social group. Clothes fit and are put on correctly

Question 11

Grooming and Hygiene

Answer 11

Clean and well groomed.

Women have moderate or no make-up

Men are shaven or have well-groomed facial hair

Nail are clean

Question 12

Level of consciousness

Answer 12

Awake, left, aware of stimuli and responds

Question 13

Facial Expression

Answer 13

Appropriate to situation and changes appropriately with topic.

Comfortable eye contact

Question 14

Speech

Answer 14

Makes laryngeal sounds effortlessly

Makes appropriate conversation

Is voice raised or muffled

One word or elaborating answers

How fast or slow they speak

Do they articulate?

Expect moderate pace and fluent stream of speech

Word choice is effortless and appropriate to educational level

Completes sentences occasionally pausing to think

Question 15

Orientation

Answer 15

To time // day of week

To place // where you are

To person // who you are and why you are there

To self // who they are, how old they are

Question 16

Attention Span

Answer 16

Ability to concentrate

Completes thoughts without wandering

Not easily distracted

Question 17

Immediate Memory

Answer 17

Ability to recall something just said

Question 18

Recent Memory

Answer 18

24 hour diet recall or how they arrived

Question 19

Remote Memory

Answer 19

Ask about verifiable past events

Question 20

New Learning

Answer 20

Four unrelated words

Carrot, ankle, fun, loyalty

Recalled immediately, at 5, 10, 30 minutes

Question 21

Insight and Judgement

Answer 21

recognition of own illness, need for treatment and consequences of behaviour as stemming from illness

Judgement is shown when patient shows their plans with regards to alternatives of treatment and going forward …plan for when they leave