Jawahar navoday vidyalaya , shegao buldana

Name

Date of birth

Age

Gender
Age: Sex: Status:
Class
Date & Time:
Father name

Mother name

Mother education/ occupation

Father education/ occupation

Address

Presenting complaints

Family history / family tree diagram

School history

General assessment

Motor skills

Self help

Communication

Academic

Socialization

Mental status examination

Name of Patient:

Name of Student:

I. PRESENTATION
 A. GENERAL APPEARANCE:

B. GENERAL MOBILITY:

1. Posture and Gait:

( ) Normal ( ) Appropriate ( ) Inappropriate

2. Activity:

( ) Normoactive
( ) Hyperactive/restless

( ) Agitated
( ) Psychomotor retardation
 3. Facial Expression:

( ) Appropriate
( ) Inappropriate

Quantity

( ) Smiling ( ) Worried ( ) Angry

( ) Happy ( ) Tensed ( ) Sad

( ) Tearful ( ) Distant ( ) Suspicious

( ) Ecstatic ( ) Frightened

C. BEHAVIOR:
D. NURSE-PATIENT INTERACTION

( ) Cooperative

( ) Initially only

( ) Uncooperative
 E. QUALITY

( ) Warm
( ) Distant ( ) Suspicious

( ) Talkative
( ) Hostile ( ) Others: ________

II. STREAM OF TALK

A. CHARACTER OF TALK

( ) Spontaneous ( ) Deliberate

B. ORGANIZATION OF TALK

( ) Relevant ( ) Irrelevant

( ) Incoherent ( ) Looseness of Association

( ) Flight of Ideas ( ) Others: _________________

C. ACCESSIBILITY

( ) Good
( ) Fair ( ) Self-absorbed

( ) Inaccessible
( ) Mute
( ) Poor

III. EMOTIONAL STATE AND

REACTION A. MOOD

( ) Euthymic ( ) Depression ( ) Euphoria

B. AFFECT

( ) Appropriate ( ) Inappropriate

C. DEPERSONALIZATION AND DEREALIZATION

( ) Present ( ) Absent

D. SUICIDAL POTENTIAL

( ) Present
( ) Absent

E. HOMICIDAL POTENTIAL

( ) Present ( ) Absent
IV. THOUGHT PROCESS

A. PERCEPTIONS

Type:

( ) Present ( ) Absent

B. DELUSION

Type: ( ) Present
( ) Absent

C. IDEAS OF REFERENCE

( ) Present
( ) Absent
 D. PREOCCUPATION AND RUMINATION

( ) Present ( ) Absent

E. DEJA’VU AND JAMAIS VU

( ) Present ( ) Absent

V. NEUROVEGETATIVE DYSFUNCTION

A. SLEEP

( ) Normal ( ) Hypersomnia ( ) Early Insomnia

( ) Late Insomnia ( ) Mixed Insomnia

B. APPETTITE

( ) Normal ( ) Increased ( ) Decreased

( ) Increased

( ) Decreased

D. DIURNAL VARIATION

E. LIBIDO

F. ATTENTION SPAN

( ) Good ( ) Fair ( ) Poor

A. ORIENTATION

Time: ( ) Unimpaired ( ) Impaired

Place: ( ) Unimpaired ( ) Impaired

Person: ( ) Unimpaired ( ) Impaired

Situation: ( ) Unimpaired ( ) Impaired

B. MEMORY

Remote: ( ) Unimpaired ( ) Impaired

Recent: ( ) Unimpaired ( ) Impaired

Immediate: ( ) Unimpaired ( ) Impaired

C. CALCULATION

Progressive subtraction of 7’s from 100.

( ) Good ( ) Fair

( ) Poor
D. GENERAL INFORMATION

( ) Unimpaired ( ) Impaired

E. ABSTRACT THINKING ABILITY

( ) Unimpaired ( ) Impaired
VII.
JUDGMENT AND REASONING

( ) Unimpaired ( ) Impaired

VIII. INSIGHT

( ) Unimpaired ( ) Impaired

IX. SUMMARY OF MENTAL STATUS EXAMINATION

A. DISTURBANCE IN

( ) Presentation
 ( ) Stream of Talk

( ) Emotional State and Reaction

( ) Thought Content

( ) Neurovegetative Dysfunction

( ) General Sensorium and Intellectual Status

( ) Insight

( ) Positive signs of Organicity

B. DIAGNOSTIC CATEGORY

( ) Functional ( ) Organic ( ) Psychotic

( ) Non-psychotic ( ) Both functional and organic

C. DSM IV DIAGNOSIS
Axis I

Axis II

Axis III

Axis IV

Axis V