Appearance:

Clothing: Neat, clean, well groomed, meticulous, clothing age appropriate, generally well groomed, clothing reflects impoverishment, shows signs of self-neglect, poor hygiene, frequently unkempt, dirty, odorous, disheveled, bizarre/eccentric (peculiar combinations, inappropriate for weather or setting...) seductive.

Physical features:

Appears stated age, appears younger (older) than stated age, tall (small) for his/her age, average, petite, obese, stocky, slim, frail, cachectic, well nourished; vagjie somatic complaints; be sure to include any unusual physical features (e.g. drooping right eyelid); frequently appears tired (dark circles under his/her eyes).

Behavior:

Calm, agitated, slowed, awkward, restless & distractible, fidgety, "hyper," needs frequent redirection, uncontrollable, sluggish, limited (or fleeting) eye contact, easily distracted, impulsive, unable to stay on task, smiling, cheerful, spontaneous, apathetic, aggressive, vigilant, disruptive, frequently interrupts, inappropriate laughing, repetitive movements/tics, compulsive hand washing (checking, counting,...), excessive masturbation.

Orientation:

Oriented X 3 (person), disoriented, oriented to time and person, but not place.

 

 

Appearance:

Cooperative, cooperative within limits, indifferent, eager to please, guarded, friendly, distant, aloof, withdrawn, flippant, reassurance, seeking, oppositional, noncompliant, provoking, contemptuous, unresponsive, defiant, seductive, aggressive, passive, hostile, sarcastic, irritable, suspicious, defensive, "whiny," clings to caretaker, inappropriately self-blaming/self-critical, fails to form attachments, forms attachments indiscriminately.

Orientation: Attitude:

Normal rate, rapid, pressured, slowed, slurred, mute, loud, echolalic, speech delay evident, incoherent, incomprehensible, word salad, rambling, garbled, nasal, stuttering.

 

Normal, no indication of delusions or hallucinations, no abnormalities of thought apparent, normal flow of ideas, relevant without evidence of unusual ideation, delusional, grandiose, suspicious, hallucinations, obsess ional, flight of ideas, bizarre, circumstantial, presence of magical thinking (age inappropriate), ideas of reference, tangential. Neutral, euphoric, euthymic, despondent, elevated, hypomanic, generally anxious (sad, depressed, fearful,...), labile, moody, dysphoric.

Speech:

Normal range, appropriate to content of speech, expansive, inappropriate, flat, restricted, blunted, tearful, anhedonia (absence of pleasure in living), gloomy, unpredictable, explosive, low frustration tolerance.

Mood: Affect:

Normal, deficit in immediate/recent/remote memory, short term/long term memory deficits, amnesia, inability to recall recent/remote past.

Appears to be of (average/below average/above average) intelligence, appears to be average to above average intelligence.