Psych (in progress)

Mental Status Examination:

Appearance -general: [select value="alert and oriented in all spheres|obtunded|disoriented|unknown"],[select value="appears to be of chronological age|appears younger than chronological age|appears older than chronological age|unknown"].
Appearance - accessibility:[select value="cooperative|friendly|uncooperative|irritated but not to the level of anger|angry|hostile|alert|confused|hostile|silent|inappropriate boundaries|seductive|playful|ingratiating|evasive|guarded|sullen|manipulative|contemptuous|demanding|withdrawn"].
Appearance - grooming: [select value="Average/WNL|well-groomed|poorly groomed|meticulously groomed|unknown"]. 
Appearance - clothing: [select value="clean|dirty|unkempt|neat|tidy|meticulous|worn out|skillfully applied|unconventional|fashionable|unknown|professional"],[select value="appropriate for season| inappropriate to season|unknown"],[select value="appropriate for setting| inappropriate for setting|unknown"]. 
Appearance - hygiene: [select value="clean|unbathed|dirty|body odor|smells of alcohol|unknown"].
Appearance - build: [select value="average height|tall|short|unknown"],[select value="average weight|thin|overweight|obese|underweight|unknown"]. 
Appearance - facial expression: [select value="casual(normal)|bland|flat|mobile(rapid changes)|angry|unknown"].
Psycho-motor activity - abnormal movements: [select value="none|grimaces|tics|twitches|foot tapping|rocking back and forth|hand wringing|ritualistic behavior|mannerisms|posturing|nail biting|chewing movements|echopraxia|tardive dyskinesia|catatonic|unknown"]. 
Psychomotor activity - rate/gait: [select value="normal|hyperactive|slow|retarded|agitated|hesitant|propulsive|shuffling|dancing|ataxic|uncoordinated|unknown"].
Psycho-motor activity - Coordination: [select value="normal/no problems|awkward|clumsy|agile|falling easily|needed assistance|bed ridden|uses wheelchair|uses walker|unknown"].
Psycho-motor activity - posture: [select value="quietly seated|relaxed|stooped|combative|hyperactive|agitated|rigid|stiff|shaky|slouched|bizarre movements|posturing|crouching|erect|restless|unknown"].
Speech: [select value="normal rate and volume|pressured|monotonous|quiet|emotional|loud|forgetful|whispering|yelling|accented|impoverished|neologisms|aphasia|global aphasia|Broca's aphasia|Wernicke's aphasia|dysarthia|preservation|sterotypy"].
Speech - clarity: [select value="clear|slurred|mumbled|lisping|stuttering|inaudible|incoherent|long pauses"].
Speech - quantity: [select value="within normal limits|responds only to questions|scant|mute|verbose|repetitive"]. 
Mood observed: [select value="euthymic|expansive|euphoric|anxious|depressed|tearful|labile|flat|happy|sad|irritated|angry|enraged|guilty|other (describe)"].
Affect: [select value="euthymic|full range of affect|broad|appropriate|constricted|blunted|flat|labile|anhedonic|blunted|emotional withdrawal|excited"]. 
Mood/affect congruence: [select value="congruent|not congruent"]. 
Behavior - general: [select value="in no distress|in mild psychological distress|in moderate psychological distress|in acute psychological distress"].
Behavior - eye contact: [select value="eye contact good|eye contact fair|eye contact avoidant|unknown"]. 
Orientation: [select value="orientated to person, place, time, and event|not orientated to person, place, time, and event|not orientated to place, time, or event|not orientated to time and event|not orientated to event|lethargic|obtundation|stupor|coma"].
Cognition/Memory - overall functioning: [select value="within normal limits|grossly intact|below average|above average|short-term memory loss|long-term memory loss|amnesia|anterograde amnesia|retrograde amnesia| history of head trauma|transient global amnesia"]. 
Cognition/Memory - abstraction: [select value="normal ability to abstract|difficulty with abstract thought|inability for abstract thought"].
Thought - form and flow: [select value="logical, relevant, and goal orientated|not logical, relevant, and goal orientated|past orientated|scattered|impoverished|racing thoughts|circumstantial|perservations|flight of ideas|illogical|hopeful|remorseful|enthusiastic|incoherent|neologism|distractable|tangential|overvalued ideas|excited|poverty of though|word salad|clang associations|slow reaction|rapid reaction|doubting|indecisive|blocking|spontaneous|pressured|"]. 
Thought - perception: [select value="within normal limits|illusions|hallucinations|denationalization|derealization"]
Thought - content: [select value="within normal limits|thought withdrawal|thought insertion|paranoia|thought broadcast|suspiciousness|grandiose delusions|somatic delusions|delusional guilt|nihilistic delusions|ideas of reference|ideas of inference|magical thinking"]. 
Insight: [select value="good|fair|poor"]. Judgment: [select value="good|fair|poor"].

Suicidality: [select value="no current ideation, plan, or intent|past ideation only|past ideation and plan only|past ideation, plan, and intent|previous attempt|current ideation, no current plan or intent|current ideation and plan, no current intent|current ideation, plan, and intent"]. Client is currently assessed to be at [select value="no|low|moderate|high"] risk for self harm as evidenced by client's self-report of [select value="not having any|having a"] suicidal ideation, and/or plan, and/or intent based upon today's exam. The following action was taken as a result of client having a suicidal ideation/plan/intent:[textarea cols="20" rows="1" default= "No action taken."]

Self-injurious behavior: [select value="no current ideation, plan, or intent|past ideation only|past ideation and plan only|past ideation, plan, and intent|previous attempt|current ideation, no current plan or intent|current ideation and plan, no current intent|current ideation, plan, and intent"]. Client is currently assessed to be at [select value="no|low|moderate|high"] risk for self-injurious harm as evidenced by client's self-report of [select value="not having any|having a"] self-injurious ideation, and/or plan, and/or intent based upon today's exam. The following action was taken as a result of client having a suicidal ideation/plan/intent:[textarea cols="20" rows="1" default= "No action taken."]

Homicidality/bodily injury towards others: [select value="no current ideation, plan, or intent|past ideation only|past ideation and plan only|past ideation, plan, and intent|previous attempt|current ideation, no current plan or intent|current ideation and plan, no current intent|current ideation, plan, and intent"]. Client is currently assessed to be at [select value="no|low|moderate|high"] risk of being a harm to others as evidenced by client's self-report of [select value="not having any|having a"] homicidal ideation, and/or plan, and/or intent based upon today's exam. The following action was taken as a result of client having a homicidal ideation/plan/intent: [textarea cols="20" rows="1" default= "No action taken."]

Additional information: [textarea cols="80" rows="3" default= "No additional information."]