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Notes

Appearance Grooming, hygiene, posture, and eye contact; correlation between appearance, developmental stage, and age.
General Attitude Cooperative, uncooperative, friendly, hostile, defensive, guarded, apathetic.
Mood Depressed, sad, anxious, fearful, labile, irritable, elated, euphoric, guilty, despairing.
Motor Activity Tremors, tics, mannerisms, gestures, gait, hyperactivity, restlessness, agitation, echopraxia, rigidity, aggressiveness.
Sensory/Perceptual Disturbances Hallucinations (auditory, visual, tactile, olfactory, gustatory). Illusions (depersonalization, derealization).
Affect Congruent with mood, flat, inappropriate.
Cognitive Alertness, orientation, memory, abstract thinking.
Speech Pattern Aphasia, volume, impairments, stuttering.
Thought Process Form of Thought: Tangentiality, word salads, neologisms, echolalia, attention span.
Content of Thought: Delusional, suicidal, homicidal, obsessive, paranoid, suspicious, religiosity-based, phobic, magical.
Impulse Control Aggression, fear, guilt, affection, sexual.
Judgment/Insight Decision making, problem solving, coping.