Physical Appearance Attire Hair Nails Skin Glasses Appropriate for occasion Clean Clean Bruised ☐ ☐ ☐ ☐ ☐ ☐ Contacts Appropriate for weather Dirty Dirty Cuts/Scrapes ☐ ☐ ☐ ☐ ☐ ☐ Hearing Aids Clean Disheveled ☐ ☐ ☐ Tattoos ☐ ☐ Describe: Dirty Styled ☐ ☐ Torn/worn through ☐ Sores ☐ ☐ Other ☐ ☐ Unusual alterations or distinguishing features: Teeth Clean ☐ ☐ Decay ☐ Missing ☐ Source of Information: Review ☐Respondent ☐Affiant ☐Chart ☐Other Behavioral Observations Activity Diminished Normal Excessive Unusual Frozen Purposeful Restless Other ☐ ☐ ☐ ☐ Catatonic Coordinated Squirming ☐ ☐ ☐ Almost motionless Fidgety ☐ ☐ ☐ Little animation Constant movement ☐ ☐ Psychomotor ☐ Hyperactive ☐ retardation Slowed reaction ☐ Other ☐ time Other ☐ Speech Slowed Normal Pressured Verbose Unusual Minimal response Initiates Excessively wordy Over productive ☐ ☐ ☐ ☐ ☐ Unspontaneous Alert/responsive Expansive winded ☐ ☐ ☐ ☐Long Sluggish Productive Rapid stop ☐ ☐ ☐ ☐Non Paucity Animated Fast Frequent run-ons ☐ ☐ ☐ ☐ Impoverished Spontaneous Rushed of ideas ☐ ☐ ☐ ☐Flight Single word ☐ Other verbal ☐Smooth ☐ ☐Hyper answers Other Other ☐ ☐ Thought Process Attention Insight Preoccupations Normal Good Somatic Self ☐ ☐ ☐ ☐ Unengaged Fair Children Finances ☐ ☐ ☐ ☐ Distractible Poor Spouse/Sig Other ☐ ☐ ☐ ☐ Hyper vigilant No insight Job ☐ ☐ ☐ Hyper focused ☐ Source of Information: Review ☐Respondent ☐Affiant ☐Chart ☐Other
Physical Appearance Attire Hair Nails Skin ☐ Glasses ☐ Appropriate for occasion ☐ Clean ☐ Clean ☐ ☐ Bruised ☐ Contacts ☐ Appropriate for weather ☐ Dirty ☐ ☐ Dirty ☐ Cuts/Scrapes ☐ Hearing Aids ☐ Clean ☐ Disheveled ☐ ☐ Tattoos Describe: ☐ Dirty ☐ Styled ☐ Torn/worn through ☐ ☐ Sores ☐ Other ☐ Teeth Unusual alterations or distinguishing features: ☐ Clean ☐ ☐ Decay ☐ Missing Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Behavioral Observations Activity Diminished Normal Excessive Unusual ☐ Frozen ☐ Purposeful ☐ Restless ☐ Other ☐ Catatonic ☐ Coordinated ☐ Squirming ☐ Almost motionless ☐ ☐ Fidgety ☐ Little animation ☐ Constant movement ☐ Psychomotor retardation ☐ Hyperactive ☐ Slowed reaction time ☐ Other ☐ Other Speech Slowed Normal Pressured Verbose Unusual ☐ Minimal response ☐ Initiates ☐ Excessively wordy ☐ Over productive ☐ ☐ Unspontaneous ☐ Alert/responsive ☐ Expansive ☐Long winded ☐ Sluggish ☐ Productive ☐ Rapid ☐Non stop ☐ Paucity ☐ Animated ☐ Fast ☐ Frequent run-ons ☐ Impoverished ☐ Spontaneous ☐ Rushed ☐Flight of ideas ☐ Single word answers ☐Smooth ☐ Other ☐Hyper verbal ☐ Other ☐ Other Thought Process Attention Insight Preoccupations ☐ Normal ☐ Good ☐ Somatic ☐ Self ☐ Unengaged ☐ Fair ☐ Children ☐ Finances ☐ Distractible ☐ Poor ☐ Spouse/Sig ☐ Other ☐ Hyper vigilant ☐ No insight ☐ Job ☐ Hyper focused Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
revised-2016-Adult-Pre-Evaluation-Screening-form.docx