Mental Health Assessment Form Template
Content
Mental Health Assessment Form
Patient name Physician Psychiatrist Date of Assessment Problem 1. 2. 3. Mental Health History/Treatment Risk Diagnosis Date of Birth Gender
Medications
Allergies
Family History of Mental Illness
Medical Conditions
Social History
Abuse history – substance/sexual/physical
Alcohol use:
Tobacco:
BMI:
Personal History (eg childhood, education, relationship history, coping with previous stressors)
1
Relevant Physical and Mental Examination
Investigations
Mental Status Examination Appearance and General Behaviour Thinking (Content / Rate / Disturbances) Perception (Hallucinations etc) Cognition (Level of Consciousness / Delirium / Intelligence) Attention / Concentration Memory (Short & Long term) Insight Orientation (Time / Place / Person) Risk Assessment Suicidal ideation Current plan Key Family/ Support Contact
Mood (Depressed / Labile) Affect (Flat / Blunted) Sleep (Initial Insomnia / Early Morning Wakening) Appetite (Disturbed Eating Patterns) Motivation / Energy Judgement (Ability to make rational decisions) Anxiety Symptoms (Physical & Emotional) Speech (Volume / Rate / Content)
Suicidal intent Risk to Others
FORMULATION – Main problem / diagnosis (risk / protective factors)
ICD – 10 Provisional Diagnosis F1 Alcohol & Drug Use disorder F2 Psychotic Disorder F3 Depression F4 Anxiety Disorder F5 Unexplained Somatic Disorder Other / Unknown:
Patient Education Notes
Yes No
Date for Mental Health Plan
Name of nurse completing assessment
Signed
Date
2
Patient name Physician Psychiatrist Date of Assessment Problem 1. 2. 3. Mental Health History/Treatment Risk Diagnosis Date of Birth Gender
Medications
Allergies
Family History of Mental Illness
Medical Conditions
Social History
Abuse history – substance/sexual/physical
Alcohol use:
Tobacco:
BMI:
Personal History (eg childhood, education, relationship history, coping with previous stressors)
1
Relevant Physical and Mental Examination
Investigations
Mental Status Examination Appearance and General Behaviour Thinking (Content / Rate / Disturbances) Perception (Hallucinations etc) Cognition (Level of Consciousness / Delirium / Intelligence) Attention / Concentration Memory (Short & Long term) Insight Orientation (Time / Place / Person) Risk Assessment Suicidal ideation Current plan Key Family/ Support Contact
Mood (Depressed / Labile) Affect (Flat / Blunted) Sleep (Initial Insomnia / Early Morning Wakening) Appetite (Disturbed Eating Patterns) Motivation / Energy Judgement (Ability to make rational decisions) Anxiety Symptoms (Physical & Emotional) Speech (Volume / Rate / Content)
Suicidal intent Risk to Others
FORMULATION – Main problem / diagnosis (risk / protective factors)
ICD – 10 Provisional Diagnosis F1 Alcohol & Drug Use disorder F2 Psychotic Disorder F3 Depression F4 Anxiety Disorder F5 Unexplained Somatic Disorder Other / Unknown:
Patient Education Notes
Yes No
Date for Mental Health Plan
Name of nurse completing assessment
Signed
Date
2
