Brief Mental Status Exam (Mse) Form
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1Brief Mental Status Exam (MSE) Form
casual dress, normal grooming and hygiene
1. Appearance
other (describe):
calm and cooperative
2. Attitude
other (describe):
no unusual movements or psychomotor changes
3. Behavior
other (describe):
normal rate/tone/volume w/out pressure
4. Speech
other (describe):
reactive and mood congruent
normal range
5. Affect
labile
depressed
tearful
constricted
blunted
flat
other (describe):
euthymic
anxious
6. Mood
irritable
depressed
elevated
other (describe):
goal-directed and logical
disorganized
7. Thought Processes
other (describe):
Suicidal ideation:
Homicidal ideation:
8. Thought Content
None
passive
active
None
passive
active
If active:
If active:
yes
no
yes
no
plan
plan
intent
intent
means
means
delusions
obsessions/ compulsions
phobias
other (describe):
no hallucinations or delusions during interview
9. Perception
other (describe):
Oriented:
time
place
person
self
10. Orientation
other (describe):
short term intact
long term intact
11. Memory/ Concentration
other (describe):
distractable/ inattentive
good
fair
poor
12. Insight/Judgement
_______________________________________________________
___________________
Practitioner Signature
Date
________________________________________________________
___________________
Patient Name
ID#
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Parent category: Medical