Adult Mental Status Examination Questionnaire Form
Please complete the Adult Mental Status Examination Questionnaire Form by responding to the following questions regarding your current thoughts, feelings, and behaviors.
Orientation: What is today’s date?
*
Attention and Concentration: How often do you find it difficult to focus on tasks?
*
Never
Rarely
Sometimes
Often
Always
Memory: Please rate your ability to remember recent events.
*
1
2
3
4
5
Mood: How would you describe your current mood?
*
Calm
Anxious
Sad
Irritable
Other
Affect: Please select the option that best describes your emotional expression during this assessment.
*
Appropriate
Restricted
Flat
Labile
Thought Process: How often do you experience racing or disorganized thoughts?
*
Never
Rarely
Sometimes
Often
Perception: Have you recently experienced things that others could not see or hear?
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No
Yes, occasionally
Yes, frequently
Insight: How would you rate your understanding of your current mental state?
*
No insight
1
2
3
4
Excellent insight
5
1 is No insight, 5 is Excellent insight
Judgment: In the past month, how often have you made decisions you later regretted?
*
Never
Once or twice
Several times
Frequently
Language: Please complete the following: "A rolling stone gathers ____."
*
Submit Assessment
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