Body Movement: WNL Accelerated Slowed Peculiar Restless Agitated WNL Cooperative Uncooperative Overly Compliant Withdrawn Sleepy Avoidant/Guarded/ Silly Nervous/ Anxious Preoccupied Restless Demanding Suspicious Behavior: Controlling Unable to perceive Provocative Hyperactive Impulsive Agitated pleasure Angry Assaultive Aggressive Compulsive Relaxed WNL Mute Over-talkative Slowed Slurred Stammering Speech: Pressured Loud Soft Clear Repetitive Emotional State- WNL Not feeling anything Irritated Happy Angry Hostile Mood (in Depressed, Anxious Afraid, person’s words): sad Apprehensive Emotional WNL Constricted Changeable Inappropriate Flat Affect Full Blunted, unvarying WNL Anxiety, fear, Sadness, depression Anger, hostility, apprehension irritability Facial Expression Elated Expressionless Inappropriate Unvarying WNL Perception: Hallucinations- Tactile Auditory Visual Olfactory ** Command Thought Content: WNL None Reported Grandiose Persecutory Somatic Illogical Chaotic Delusions- Religious Preoccupied Obsessional Guarded Phobic Suspicious Guilty Other Content- Thought Thought insertion Ideas of reference broadcasting Decreased thought Flight of WNL Incoherent Blocked flow ideas Thought Process: Loose Racing Chaotic Concrete Tangential Intellectual Lessened fund of Impaired Impaired calculation Functioning: WNL common concentration ability knowledge Intelligence Develop. No formal Borderline Average Above average Estimate - Disabled testing Orientation: WNL Disoriented to: Time Place Person Remote Short Attention Memory: WNL Impaired: Immediate recall Recent memory memory Span Difficulty acknowledging presence of Mostly blames other WNL Thinks he/she has no problems Insight: psychological problems for problems Impaired Ability to Make Judgment: WNL Mild Moderate Severe** Reasonable Decisions: Past Attempts to Harm Self or Self** Others** None Reported Others: Self Abuse None reported Cutting** Burning** Other: Thoughts: Suicidal None reported Passive SI** Intent** Plan** Means** Thoughts: Aggressive None reported Intent** Plan** Means** Thoughts: Comments: Record #: Person’s Name (First MI Last): Person’s Served Strengths/Abilities/Resiliency (Skills, talents, interests, aspirations, protective factors) Personal Qualities: (Examples: open, friendly, engaging, motivated, loyal, resourceful, caring, thoughtful) Living Situation: (Examples: has maintained long-term stable housing, gets along with living companions)
Body Movement: WNL Accelerated Slowed Peculiar Restless Agitated Behavior: WNL Cooperative Uncooperative Overly Compliant Withdrawn Sleepy Silly Avoidant/Guarded/ Suspicious Nervous/ Anxious Preoccupied Restless Demanding Controlling Unable to perceive pleasure Provocative Hyperactive Impulsive Agitated Angry Assaultive Aggressive Compulsive Relaxed Speech: WNL Mute Over-talkative Slowed Slurred Stammering Pressured Loud Soft Clear Repetitive Emotional (in person’s words): WNL Not feeling anything Irritated Happy Angry Hostile Depressed, sad Anxious Afraid, Apprehensive Emotional State- Affect WNL Constricted Changeable Inappropriate Flat Full Blunted, unvarying Facial Expression WNL Anxiety, fear, apprehension Sadness, depression Anger, hostility, irritability Elated Expressionless Inappropriate Unvarying Perception: WNL Hallucinations- Tactile Auditory Visual Olfactory Command ** Thought Content: WNL Delusions- None Reported Grandiose Persecutory Somatic Illogical Chaotic Religious Other Content- Preoccupied Obsessional Guarded Phobic Suspicious Guilty Thought broadcasting Thought insertion Ideas of reference Thought Process: WNL Incoherent Decreased thought flow Blocked Flight of ideas Loose Racing Chaotic Concrete Tangential Intellectual Functioning: WNL Lessened fund of common knowledge Impaired concentration Impaired calculation ability Intelligence Estimate - Develop. Disabled Borderline Average Above average No formal testing Orientation: WNL Disoriented to: Time Place Person Memory: WNL Impaired: Immediate recall Recent memory Remote memory Short Attention Span Insight: WNL Difficulty acknowledging presence of psychological problems Mostly blames other for problems Thinks he/she has no problems Judgment: WNL Impaired Ability to Make Reasonable Decisions: Mild Moderate Severe** Past Attempts to Harm Self or Others: None Reported Self** Others** Self Abuse Thoughts: None reported Cutting** Burning** Other: Suicidal Thoughts: None reported Passive SI** Intent** Plan** Means** Aggressive Thoughts: None reported Intent** Plan** Means** Comments: Person’s Name (First MI Last): Record #: Person’s Served Strengths/Abilities/Resiliency (Skills, talents, interests, aspirations, protective factors) Personal Qualities: (Examples: open, friendly, engaging, motivated, loyal, resourceful, caring, thoughtful) Living Situation: (Examples: has maintained long-term stable housing, gets along with living companions) Mood
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