PSYCHIATRIC INITIAL EVALUATION

(2/21/23)

NAME: _________________________________________ SEX: ________________________________________

AGE: ___________________________ PLACE/ DATE OF BIRTH: _______________________________________
CIVIL STATUS: ______________ ADDRESS: _________________________________________________________
RELIGION: _______________ OT – IN – CHARGE: ____________________________________________________
DIAGNOSIS: ___________________ DOCTOR-IN-CHARGE: ___________________________________________
OT CLINICAL IMPRESSION: _______________________________________________________________________
MEDICATIONS: ________________________________________________________________________________
PRECAUTIONS: _______________________________________________________________________________

SUBJECTIVE:
Informant:_________________
I. Chief Complaint (C/C)
⮚ Presenting complaint (verbatim/ informant)
⮚ Pt’s. own words or informant/s’ why he or she has come or been brought in for help.
II. Premorbid Personality
⮚ (before Sx appeared)
⮚ Caretaker/ chart/ not determined if none
III. HPI (paragraph form)
⮚ Through caretaker, Pt. (interview), chart
⮚ Onset and precipitation factors
⮚ cause/reasons of admission
⮚ provides a comprehensive and chronological picture of the events leading up to the current
moment in the patient's life
IV. Family History
⮚ brief statement about any psychiatric illness, hospitalization, and treatment of the patient's
immediate family members
⮚ provide a description of the personalities and intelligence of the various persons living in the
patient's home from childhood to the present as well as a description of the various
households in which the patient lived ⮚ state if single, married, divorced

A. Single/ Married
1. If single:
a. # of siblings
b. Rank of Pt
c. Parents (living/ deceased, & occupation)
d. Closest sibling
e. Closest parent
f. Best friend/s
2. If married:
a. # of children
b. Age range of children (eldest: ___ youngest: ___)
c. # of married children
d. # of working children
e. Child closest to
f. Name of spouse
B. Relationship with parents/ siblings/ spouses/ children (paragraph form)
⮚ Pt’s. attitudes toward his sibling and family members
⮚ Pt’s. description of the parents’ occupation
⮚ What does each sibling do in comparison to what the Pt. is doing?
V. PERSONAL HISTORY (ANAMNESIS)
A. Prenatal and Perinatal Hx (paragraph form)
⮚ Events before and during birth of the Pt.
⮚ Was the Pt. wanted/ planned
⮚ Problems during pregnancy and delivery
⮚ Did mother use alcohol or any substances
B. Early Childhood (0-3 years) (paragraph form)
⮚ Parent-child interactions
⮚ Play hx
⮚ Feeding habits, early devt., toilet training
⮚ Beh. Problems, personality as a child
⮚ Dreams/ fantasies
C. Middle Childhood (3-11 yrs.) (paragraph form)
⮚ Relationships at school, home, and at play
 D. Late Childhood (Puberty to Adolescence) (paragraph form)
⮚ Social relationships
⮚ School hx, cognitive and motor devt.
⮚ Emotional and physical problems
⮚ Sexuality issues
E. Adulthood (paragraph form for each subarea)
a. Educational Background
⮚ Highest education attained
⮚ Attainment of siblings in relation to the Pt’s
⮚ Pt’s attitude towards academic achievement
b.Work History
⮚ Occupation prior to d/a or present occupation
⮚ Duties/ responsibilities in present job
⮚ Other work experience
⮚ Present means of support
c. Hobbies/ Interest and Social Activities
d.Marital and Relationship Hx
e. Religion
f. Current Living Situation
⮚ Neighborhood and residence
⮚ Sources of family income and financial hardships
⮚ Home situation
g. Legal Hx
⮚ Arrests, or any acts of violence
h.Psychosexual Hx
⮚ Any sexual problems and relationships

OBJECTIVE:
(indicate grade before every item)
Mental Status Exam

⮚ part of the clinical assessment that describes the sum total of the examiner's observations and
impressions of the psychiatric patient at the time of the interview
⮚ description of the patient's appearance, speech, actions, and thoughts during the interview

A. General Appearance (paragraph form)

1. Characteristics that make Pt. unique (very detailed)
2. Body Type
a. Ectomorphic - characterized by long and thin muscles/limbs and low fat storage; receding
chin, usually referred to as slim
b. Mesomorphic -characterized by medium bones, solid torso, low fat levels, wide shoulders
with a narrow waist; usually referred to as muscular.
c. Endomorphic - characterized by increased fat storage, a wide waist and a large bone
structure, usually referred to as fat.
3. Dressing (appropriateness; describe in detail what Pt. is wearing)
4. Grooming & hygiene (hair, teeth, breath, nails)
5. General health (sick, well, string, healthy)
6. Posture (slouched, relaxed, tense, rigid, erect, stooped)
7. Anxiety signs: moist hands, perspiring forehead, tense posture, wide eyes

B. General Behavior (paragraph form)

⮚ Habits, peculiarities, unusual behavior
⮚ Increase (restlessness) or decreased motor act. (Psychomotor retardation)
⮚ Negativism
⮚ Compulsive behavior
⮚ Attention-seeking behavior
⮚ Tics, mannerisms
⮚ Restlessness, wringing of hands, pacing
⮚ Speech
∙ Spontaneous (able to answer questions)
∙ Quantity (talkative and spontaneous)
∙ Quality (echolalia, stutters)
∙ Rate (slow, pressured, monotonous)
∙ Aphasic
∙ Dysarthric
∙ Talkative
∙ Eye contact
∙ Volume
 ∙ Pitch (be specific)
⮚ Attitude towards examiner
∙ Friendly, attentive, interested, frank, cooperative, seductive, defensive, contemptuous,
apathetic, hostile, playful, evasive or guarded
∙ Level of rapport established
C. Emotional State (paragraph form)
1. Mood (pervasive & sustained emotion Pt. feels, verify through verbalizations)
⮚ Can either be:
Decreased Labile
Euthymic Dysthymic
Elevated Ecstatic
Euphoric Irritable
Angry Anxious
Panic Agitated
2. Affect (facial expression)
⮚ Can either be:
Flat
Blunted
Constricted
Appropriate
Inappropriate
⮚ Appropriateness
e.g. Pt. with delusion of persecution should display anger or fear

D. Mental Activity/ Thought Activity

1. Perceptual Disturbances (indicate whether, or)
⮚ Hallucinations (write Pt’s verbalizations)
∙ Visual
∙ Auditory
∙ Tactile/ haptic
* Rule out hallucinations by asking Pt. in detail the content of his hallucinations
* Rule out pseudohallucinations
⮚ Illusions
2. Content of Thought
⮚ Delusions
∙ Persecutory
∙ Grandiose
∙ Erotomanic
∙ Paranoid
⮚ Phobia
⮚ Preoccupations (suicidal, homicidal)
⮚ Ideations (sexual, religious)
⮚ Obsessions/ compulsions
⮚ Ideas of reference and influence
⮚ Poverty of content

3. Schneiderian Symptoms
Tester’s Question Patient’s Response

a. Thought Blocking Naa bay butang o

(Abrupt interruption in train of thinking before a thought tawo nga ning
or idea is finished; after a brief pause, the person barasa imong
indicates no recall of what was being said or was going huna-huna?
to be said)

b. Thought Control Naa bay butang o

( is attributed to someone other than the person having the tawo nga ning
delusion and usually implies action control. E.g., someone control sa
who commits a crime and attributes the action to the force imong huna-huna?
of a spirit or devil.)

c. Thought Broadcasting Sa imong opinyon,

(believes that his or her thought can be transmitted) ang imong mga
gipanghuna-huna
madunggan ba sa
radyo o ipakita sa
 TV?

d. Thought Insertion Naa bay butang o

( believes that someone or something is responsible for tawonga mu suksok
either putting thoughts into one’s brain) ug mga ideya sa
imong huna-huna?

e. Thought Withdrawal Naa bay butang o

( believes that someone or something is responsible tawo nga mukuha o
for removing one’s thoughts – ability to think) musibog para
mawala ang imong
gihuna-huna?

4. Flow/ Process of Thought

Term Description Example

Concreteness Extremely literal verbal “Reading can open a whole

responses due to concrete new world” Response “and
thinking patterns. The speaker the lava flows out of the
does not recognize the nuances cracks”
of language, including
abstractions or metaphors

Flight of Ideas (mood) Rapid succession of what of

fragmentary thoughts or speech
in which content changes
abruptly and speech may be
incoherent.

Loosening of Associations (schiz) Ideas shift from one subject “What is your name?” Response
to another that is “ A rose by any other name….I
completely wish I could get out of
unrelated. The speaker does not here…Jigsaw puzzles are fun.”
show any awareness that the
topics are unconnected

Perseveration Repetition of the same word, “ What do you want to do

phrase, or idea. Also, an inability today?. Response “Today is
to shift from one task to another. Tuesday. I always was on
Tuesday. Always on Tuesday, it’s
wash.”

Circumstantiality and Tangentiality The person disgresses, giving “When were you in the
unnecessary, irrelevant hospital?” Circumstantial
information. When speech is response: “I went to this great
circumstancial, there is difficulty concert last summer after I
getting to the point of the visited my aunt.” Tangential
conversation, yet in the person’s response: In the fall….the leaves
mind, the answers are related. In were so beautiful…They were
tangential speech, the person like paintings. My art is my soul.”
starts answering a question but
then rapidly digresses.

Echolalia Repetition (echo) of the words “What is your name?”

and phrases of others. This Response: “ What is your
speech is repetitive and name? Your name, your name.”
persistent.

Clanging The sound or rhyme of the words “What is your occupation?”

takes precedence over the Response: “ I used to be a
meaning or content of the lawyer, now a liar, lollipops,
replies. licenses, and licorice.”

Neologism An invented word that may “Why were you admitted to the
closely resemble an existing hospital?” Response: “ It come
word or may be known only to from too much normiation, a sort
the individual. of infestation of some sort. I was
 being institized.”

E. Sensorium and Cognition

1. Level of Consciousness
⮚ Disorientation, clouding, stupor, delirium, coma, coma vigil, etc.
2. Cognition
2a. Orientation Intended Patient’s
Score Score

Name this hospital or building. Unsay ngalan sa aning lugara nga naa 1
ka karon?

What city are you in now? Asa ka na siyudad karon? 1

What year is it? Unsa man ang tuig karon? 1

What month is it? Unsa man ang buwan karon? 1

What is the date today? Unsa man ang petsa karong adlawa? 1

What country are you in? Unsa nga nasod nga naa ka karon? 1

What province are you in? Unsa nga probinsiya nga naa ka karon? 1

What floor of the building are Unsa nga floor (1/2/3) nga naa ka karon? 1
you in?

What day of the week is it? Unsang adlawa karon karong semanaha? 1

Name the current president. Ngalan sa atong president sa Pilipinas? 1

2b. Registration

Name 3 objects. Toothbrush. Sapatos. Tinidor. 3

2c. Attention & Calculation

Subtract 7 from 100 up to 65. 93 – 86 – 79 – 72 – 65 5

2d. Recall

Do you recall the 3 objects Makahinumdum pa ka sa atong tulo 3

named before? ka butang nga akong gipaila sa imo
ganiha?

2e. Language

1. Confrontation naming. Watch. Ballpen. 2

2. Repetition “No pain no gain.” 1

 3. Comprehension: Pick up Punita ang papel sa imong tuo na 3
the paper kamot, tunga-a ug pilo ug ibutang sa
in your right hand, fold it in salog.
half and
set it on the floor

4. Read and perform the 1

command:
“Close your eyes”

5. Write any sentence 1

(subject verb,
object)

2f. Construction: Let the Geometric Christmas tree (triangular) 1

patient copy with star.
a design/ drawing.

TOTAL 30

▪ Total MMSE score (max = 30)

25-30 = Good and Intact Cognition
20 -24 = Possible Impairment in cognition
Below 20 = Definite impairment in cognition
▪ Note: In any area of the MMSE therapist questions must be question mark while Pt. answers are put in a
quotation marks. Always remember that at least 3-5 questions are asked to verify any area of the
MMSE. This is highly needed in areas graded as either poor, fair, good. Don’t follow what’s asked from
this book. Be imaginative and original.

F. Judgement
i. Intellectual

Tester’s Questions
a. Kung maka punit ka ug pitaka nga naai ID ug kwarta sa sulod, unsa imong buhaton?
b. Kung mag linog, unsa imong buhaton?
c. Kung masaag ka sa usa ka lugar, unsa imong buhaton?

Patient’s Responses
1.
2.
3.

ii. Social

Tester’s Questions
a. Unsa imong opiniyon or pananaw sa corruption?
b. Unsa imong opiniyon or pananaw sa poverty?
c. Unsa imong opiniyon or pananaw sa abortion?

Patient’s Answers
1.
2.
3.
LEGEND:
Good – able to answer 3 questions correctly and properly
Fair – able to answer 2 of 3 questions correctly and properly
Poor – able to answer 0/1 of 3 questions correctly and properly

G. Abstract Thinking

1. Similarities and Differences

Objects Similarities Differences
 Taxi Jeep

TV Radio

Chair Table

Pencil Ballpen

Legend:
Poor = cannot detect differences/ similarities
Fair = differences/ similarities are concrete
Good = more of fxn, sim/diff are visible or seen

Proverb Patient’s Response

1. Honesty is the best policy.

2. Kung unsa imong gitanom, mao sad

imong anihon.

3. Do unto others, what you want others to

do unto you.

LEGEND:
Good – able to answer 3 questions appropriately
Fair – able to answer 2 of 3 questions appropriately
Poor – able to answer 0/1 of 3 questions appropriately

H. Attitude Towards Self

1. Self-esteem
LEGEND:
Good – can identify assets and liabilities
Fair – able to identify assets and liabilities given encouragement and prodding
Poor – cannot identify assets and liabilities

⮚ Ask Pt. to state assets & liabilities

* If he does not answer, ask what he sees/ wants in his/her friends
⮚ Also verify this through verbalizations

2. Self-confidence
LEGEND:
Good – able to carry out talents and abilities without hesitations
Fair – hesitant n executing one’s abilities and needs furthermore encouragement
Poor – unable to carry out one’s abilities

⮚ Can he do activity or not

⮚ Ask about leadership potentials
* Note: self-esteem plus self-confidence equals self-concept

I. Attitude Towards Others

⮚ IPR Skills
LEGEND:
Good = can initiate, sustain and terminate conversation
Fair = able to sustain but not initiate/ able to initiate but unable to sustain and terminate
conversation Poor = cannot initiate, sustain nor terminate conversation
 o Also note if Pt. is helpful, competitive, manipulative
o Indicate relationships with family, hospital, staff, co-Pts. (nature & degree)

J. Insight - the patient's degree of awareness and understanding about being ill
o Levels of insight
1. Complete denial of illness
2. Slight awareness of being sick and needing help, but denying it at the same time
3. Awareness of being sick but blaming it on others, on external factors, or on organic factors
4. Awareness that illness is caused by something unknown in the patient
5. Intellectual insight: admission that the patient is ill and that symptoms or failures in social adjustment are caused by
the patient's own particular irrational feelings or disturbances without applying this knowledge to future experiences 6.
True emotional insight: emotional awareness of the motives and feelings within the patient and the important persons
in his or her life, which can lead to basic changes in behavior.

WORK BEHAVIOR
A. Attitude towards work/act./interview
⮚ Motivation,
⮚ approach to act.
LEGEND:
Good - no prodding, active participation
Fair - passive to active participation, (+) mod. prodding
Poor - Pt. doesn’t participate, passive participant, needs maximal prodding

B. Work Ability

1. Follows instruction
LEGEND:
Good – able to follow instruction effectively
Fair – able to follow instructions but has to repeat he procedures several times
Poor – difficulty following instructions and needs to be refreshed and guided throughout the activity

⮚ Demo/ oral (visual/ auditory)

⮚ Written (higher form)

2. Organize & initiate work

LEGEND:
Good – excellent organization and initiative, able to plan and sort independently
Fair – Developed a plan with assistance; needed help in breaking task into sequential steps
Poor – difficulty in organizing and initiating an activity ; trial and error approach

3. Supervision needed
LEGEND:
No supervision needed – can complete an activity even without the presence of therapist
Minimal Supervision – can do 75% of the activity; needs 25% of therapist’ support to complete the activity
Moderate Supervision – can do 50% of the activity; needs 50% of therapist’ support to complete the activity
Maximal Supervision - can do only 25% of the activity; but still needs therapist’ full support to complete the
activity

4. Attention span
LEGEND:
Good – attends to activity within ≥ 30 minutes
Fair – attends to activity within 15 to 29 minutes
Poor – attends to activity less than 15 minutes

5. Concentration
LEGEND:
Good – able to accomplish activity without being distracted (no problems noticed in working
environment, with others doing loud tasks)
Fair – able to accomplish activity but easily distracted, however able to return to activity
given when prompted (in working environment, with others doing quite task)
Poor – easily distracted, unable to accomplish task given (worked only when
environmental distractions were at a minimum, outside the group)
 6. Skill (quality of project) (when applicable)
LEGEND:
Good – has appropriate skill in performing the task and uses materials properly without cueing or assistance
Fair – has appropriate skill in performing the task and uses materials properly w/
moderate cueing or assistance Poor – has inappropriate skill in performing a task and
improper use of materials

7. Frustration Tolerance
LEGEND:
Good – able to finish activity without signs of frustration, irritability or giving up with more difficult
task Fair – able to finish activity but needed to be prompted by therapist in order not to give up
Poor – unable to finish activity or easily frustrated with simple task

8. Impulse Control
LEGEND
Good – thinks before acting and waits for signals
Fair – thinks before acting but can’t wait for signals
Poor – acts out immediately on impulse

9. Problem solving
LEGEND
Good - Able to recognize problems and find realistic solutions independently
Fair – Able to recognize problems but cannot foresee solutions
Poor - Unable to recognize problems or suggest solutions

10. Decision-making
LEGEND
Good – able to make decisions effectively without relying on others
Fair – able to make decisions but relies on other opinion and feedback
Poor – always relies on others on making decisions

K. PSYCHODYNAMICS (Reason for using such an assessment tool)

L. BATTERY TEST RESULTS AND INTERPRETATION

ASSESSMENT:

Integrate the results of your evaluation by:

∙ Identifying the pt’s strengths and weaknesses in a tabular form:

ASSETS DEFICITS

∙ Stating your hypothesized prognosis in performance areas based from your findings noted during the
interview, clinical evaluation, and medical prognosis (according to literature).

- Pt has (good/ guarded/ poor) prognosis in (area) (performance, skills, and contexts)

∙ Determining your OT problem list by assessing which activity demands, contexts, performance skill
deficits, missing performance components or client factors are limiting occupational performance

OT PROBLEM LIST

1. Pt has difficulty in (Performance Area) secondary to (which activity demands, contexts, performance skills
deficits, missing performance components or client factors are limiting occupational performance)
associated with / secondary to (MEDICAL DIAGNOSIS)
2.
PLAN

TREATMENT PLANNING
1. Problem
Long Term Goal
∙ The acceptable form: To improve (AREA):

Short Term Goals

∙ Patient will be able to (description of specific steps of the functional activity expected of the
patient) given (conditions/criteria, such as level of independence, materials/equipment to be
used, etc) after (# of sessions). POA:
∙ TUA:
∙ TUS
∙ Purposeful activities

RECOMMENDATIONS:

OT-in-charge OT Clinical Supervisor