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HPI
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PAST PSYCHIATRIC HISTORY
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MEDICAL HISTORY
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SUBSTANCE USE HISTORY
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SOCIAL/DEVELOPMENT HISTORY
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FAMILY HISTORY
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SOCIAL HISTORY
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EDUCATIONAL HISTORY
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WORK HISTORY
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LEGAL HISTORY
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Subjective
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Objective
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Assessment
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Plan
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MENTAL STATUS EXAMINATION
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APPEARANCE
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Groomed
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Dress
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How?
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Weight
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ATTITUDE
• • •
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MOTOR
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CONSCIOUSNESS
• • •
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SPEECH
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Tone
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Speed
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MOOD
• • •
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AFFECT
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How?
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THOUGHT PROCESS
• • •
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THOUGHT CONTENT
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THOUGHT CONTENT
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Which?
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Obsessions
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Which?
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Suicidal Ideas
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Plan?
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Homicidal Ideas
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Plan?
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JUDGEMENT
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INSIGHT
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ATTENTION
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Repeat 5 words
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CONCENTRATION
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Spell word backwards
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MEMORY
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Immediate
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Repeat 5 words in 5 minutes
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Recent
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Repeat events
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Remote
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Remote events
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MULTIAXIAL DIAGNOSIS
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Axis I
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Axis II
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Axis III
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Axis IV
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Axis V
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ASSESSMENT
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PLAN
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