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Psychiatric Screening Cheat Sheet by

Initial psychiatric screening.

Legal Status

Baker Act | Marchman Act | Ex-Parte | Voluntary
Initiated by: Judge | Police | Provider | Other
If police, specify depart­ment:

Mental Status Exam

Appe­ara­nce | Approp­riate | Disheviled | Other
Mood | Approp­riate | Angry | Sad | Manic | Other
Affect | Approp­riate | Flat | Restricted Other
Motor Behavior | No Abnorm­alities Catatonic
Speech | Unrema­rkable Pressured Hesitant
Thought Process | Coherent Incoherent
Judg­eme­nt/­Ins­ight | Adequate Fair Poor
AVH/­Del­usi­ons | Present Not Present Other
 

Presenting Problem

Symp­toms
Hist­ory
Suicidal Threat­/At­tempt | Homicidal Threat­/At­tempt | Self-I­nfl­icted Injury | Traumatic Event | Legal Court Order | Physician Order | Impuls­ive­/Da­ngerous Behavi­orP­syc­hotic Features | Cognitive
Psychi­atric Treatm­ent­/Ho­spi­tal­ization | ECT | Substance Abuse Treatment | No Previous Treatment

Living Status

Marital Status
Current Living Arrang­ement
Single
House/­Apa­rtm­ent­/Ho­meless
Married
SNF or ALF?
Divorced
Lives with:
Other:
 

Substance Use

Active Abuse | Past History | No History
Substance:
Active | Early Remission | Sustained Remission
Route:
Frequency:

History of Abuse/­Trauma

Yes
Physical | Sexual | Emotional
 
Traumatic event:
No

Sleep

Symp­toms
Prom­otion
Difficulty Falling Asleep
Relaxation Techniques
Difficulty Staying Asleep
Avoid Naps
Nightmares
Avoid Stimulants
Napping
Ear Plugs/Face Mask
Other:
Other:
 

Nutrition

History of Eating Disorder Yes | No
Weight Change in Last 3 Months Yes | No
Weight Change in Last 6 Months Yes | No
Intent­ional Weight Change Yes | No
Appetite Increased Yes | No
Appetite Decreased Yes | No
 

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