Mental Health Assessment Form

Mental Health Assessment Form
Please fill-up the form below. If you have any questions, kindly contact us at (123) 1234567 or email us at info@abcmentalhealth.com.
Patient Information
Patient ID
Full Name
First NameLast Name
Nick Name
Age
Date of Birth
MonthDayYear
Date
Gender
MaleFemale
Race
American IndianAsianBlack or African AmericanNative HawaiianWhite
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Employment Status
Employed, Self-employed, unemployed
Emergency Contact Person
First NameLast Name
Emergency Contact Phone Number
Mental Health Exam
Assessment Start Date/Time
MonthDayYear
Date
Hour MinutesAM/PM Option
Assessment End Date/Time
MonthDayYear
Date
Hour MinutesAM/PM Option
Primary Concern (symptoms, duration, intensity)
Family Relationship/Interpersonal (Kindly describe the social relationship of the patient to anyone.)
General Appearance
NormalEmaciatedObesePoor HygieneOther
Motor Activity
NormalAgitationRepetitive ActionsTremorsDistinct PosturingOther
Judgment
GoodFairPoor
Memory
IntactPoor DistantPoor Recent
Concentration
GoodDistractibleVariable
Insight
GoodFairPoor
Cognitive
IntactImpaired
Speech
NormalPressuredSlurredSoftStutteringHesitant
Affect
AppropriateAnxiousBluntedDepressedIrritableOther
Daily Patterns
Normal SleepPoor SleepNightmaresFatigueNormal AppetiteSocial Withdrawal
Checking Mental State
Status Remarks
Appearance
Behavior
Conversation
Affect
Perception
Cognition
Any current or history of violent behavior? If yes, please explain below when, how, and what happened.
Does the patient have any past or current medical condition that you would like to declare? (head injury, accident, etc.)
Is there any previous hospitalization? If yes, please explain the reason. If no, leave blank
Does the patient have any allergies? If yes, please list them below:
Is the patient currently taking any medications? If yes, please list them below:
Diagnosis and Treatment
Mental Health Diagnosis
Plan of Treatment
Medications (If needed)
Medication name Dosage/Frequency Time Purpose
1
2
3
4
5
6
7
Health Care Worker Name
First NameLast Name
Position Title
Health Care Worker Signature
Clear
Date Signed
MonthDayYear
Date
Should be Empty:

	Status	Remarks
Appearance
Behavior
Conversation
Affect
Perception
Cognition

	Medication name	Dosage/Frequency	Time	Purpose
1
2
3
4
5
6
7

Mental Health Assessment Form

Patient Information

Mental Health Exam

Diagnosis and Treatment