Mental Status Examination Screening Form For Mental Disorders
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1Mental Status Examination Screening for Mental Disorders
Orientation
(Add Points for each correct Response)
Score
Points
1. What is the:
Year?
1
Season?
1
Date?
1
Month?
1
2. Where are we:
State?
1
County?
1
Town or City?
1
Hospital?
1
Floor?
1
Registration
3
3. Name three objects, taking one second to
say each. Then ask the patient all three after
you have said them. Give one point for each
correct answer. Repeat the answers until the
patient learns all three.
Attention and Calculation
5
4. Serial sevens. Give one point for each
correct answer. Stop after five answers.
Alternate: Spell WORLD backwards.
Recall
3
5. Ask for the names of the three objects
learned in question 3. Give one point for
each correct answer.
Language
2
6. Point to a pencil and a watch. Have the patient
name them as you point.
7. Have the patient repeat, “No ifs, ands, or buts.”
1
8. Have the patient follow a three-stage command:
3
1. Take a paper in your right hand.
2. Fold the paper in half.
3. Put the paper on the floor.
9. Have the patient read and obey the following:
1
“Close your eyes.” (Write in large letters).
10. Have the patient write a sentence of his or her
1
choice. (The sentence should contain a subject and an
object), and should make sense. Ignore spelling errors
when scoring.
11. Have the patient copy the design below on a
1
separate sheet. (Give one point if all sides and angles
are preserved and if the intersecting sides and angles
are preserved and if the intersecting sides form a
quadrangle).
Examination Date:
Total out of 30
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Parent category: Medical