The information required on a mental status examination form include appearance, behavior, motor activity, speech and mood, states the American Family Physician. It also includes thought process and content, perceptual disturbances, cognition, insight and judgement. The mental status examination is a tool that helps the physician make psychiatric diagnoses.
The mental status examination form documents whether the patient has an unkempt or dishevelled appearance, and whether he is calm and cooperative or agitated. It also documents posture, movements and facial expression. The quantity, rate, volume and fluency of the speech is noted, including whether speech is coherent or incoherent. The patient is asked about his mood and his affect, which is the expression of his mood.
According to the American Family Physician, the patient's flow of thought and form of thinking are documented in the mental status examination form. The examiner documents whether the patient has any obsessions, delusions, phobias or hallucinations, and whether he has any thoughts of harming himself or others. The patient's level of consciousness is documented, as well as his attention level, memory and concentration. Insight, which is the patient's awareness and understanding of his condition, is noted. The patient's judgement or ability to recognize the consequences of actions is also assessed.