Patient Name/Code:
Duration illness:


Is the patient untidy
Is the patient very messy
Is the patient wearing excessive jewelry makeup and eccentric clothing
Does the patient move slowly
Does the patient appear stiff or frozen
Is the patient restless, in constant motion
Does the patient look agitated, on the verge of exploding
Does the patient exhibit bizarre unexplainable movements
Does the patient have repetitive stereotypic movements
Does the patient speak slowly
Does the patient have limited verbal communication, e.g. short responses
Does the patient answer with only a few words or none at all
Does the patient speak in a low tone or whisper
Does the patient speak fast
Does the patient speak a lot, give long spontaneous responses
Does the patient speak without stopping jumping from one subject to another
Does the patient speak with an elevated tone
Are the patient’s speech associations loose
Words are unrelated within sentences ‘word salad’
The patient repeats the same topics of conversation
The patient repeats /perseverates the same sentences
The patient responds to previous questions
Obsessions and compulsions
Delusion, false unshakable beliefs
Systemized delusions
Inappropriate affect
Flight of ideas
Speech content includes mainly issues of despair, hopelessness, and pessimism.
Speech content includes mainly issues of megalomania, over empowerment and unrealistic optimism (and plans)
Bizarre or overly abstract response to categorization (proverbs) and abstraction
Concrete interpretation of proverbs and low abstraction
Auditory hallucinations
Visual tactile olphactory hallucinations
Constricted affect
Blunt affect
Expansive mood elevated affect
Dysphoric (suffering) affect
Depressed affect
Anxious affect
Detached from examiner
Perplexed, ambivalent
Inappropriately close to examiner (no boundaries)
Suspicious with examiner
Threatening to examiner
Seductive toward examiner (theatrical)
Sensitive easily offended
Childish dependent regressive
Manipulating demanding
Stubborn obsessive non adaptable
Tends to idealize or devaluate examiner
Egocentric not empathic
Memory loss


Complaints of insomnia or hypersomnia
Complaints of early insomnia
Complaints of late insomnia
Complaints of anorexia, weight loss
Complaints of palpitations, dizziness, abdominal cramps and tingling
Complaints of anxiety fear of dying or losing control, panic
Complaints of fear of dying or losing control panic in specific situations
Complaints of tension restlessness and agitation
Complaints of avolition indifference apathy anhedonia
Complaints of depressed mood
Complaints of depressed mood especially in the morning
Complaints about flight of ideas
Complaints that things are strange, unfamiliar, changing, not as usual (dereism, depersonalization)
Complaints of external control, mind reading, bugging, persecution (about delusions)
Complaints related to systemized delusion
Complaints of low self esteem
Complaints of being easily offended, oversensitive
Complaints of being impulsive


History of Delusions
History of Hallucinations
History of thought disorders loosening of associations
History of thought disorders perseverations poverty of thought
History of depressions
History of mania
History of anxiety
History of phobias
History of disturbed upbringing, parental loss
History of behavioral problems
History of deficiencies in coping at work and in social situations
History of unstable interpersonal relationships
History of psychosocial or other stress (regular life stressors)
History of trauma (stressor exceeding regular life stress)