Psych

General Appearance

• Grooming & Hygiene: Well-groomed, disheveled, neglected.
• Dress: Appropriate, inappropriate, bizarre.
• Posture: Relaxed, rigid, slouched, withdrawn.
• Eye Contact: Normal, poor, intense, avoidant.
• Motor Activity: Normal, restless, slowed, tics, tremors.

Behavior

• Attitude: Cooperative, guarded, hostile, evasive.
• Interaction: Engaged, withdrawn, aggressive, inappropriate.
• Responsiveness: Attentive, distractible, preoccupied.

Speech

• Rate: Normal, slow, rapid, pressured.
• Rhythm: Regular, hesitant, irregular.
• Volume: Normal, soft, loud, whispered.
• Fluency: Clear, slurred, mumbled, dysarthric.

Mood & Affect

• Mood (Patient’s Report): Normal, depressed, anxious, irritable, elated.
• Affect (Observed Expression): Normal, flat, blunted, constricted, labile.
• Congruence: Mood-congruent vs. incongruent.

Thought Process

• Flow: Goal-directed, circumstantial, tangential, flight of ideas.
• Disruptions: Loose associations, thought blocking, perseveration.

Thought Content

• Delusions: Persecutory, grandiose, referential, somatic, nihilistic.
• Obsessions: Intrusive repetitive thoughts.
• Compulsions: Repetitive behaviors.
• Paranoia: Suspicious, hypervigilant.
• Phobias: Excessive fears.
• Suicidal/Homicidal Ideation: None, passive, active, intent, plan.

Perception

• Hallucinations: Auditory, visual, tactile, olfactory, gustatory.
• Illusions: Misinterpreted stimuli.
• Depersonalization: Detached from self.
• Derealization: Environment feels unreal.

Insight & Judgment

• Insight: Good, fair, poor, absent.
• Judgment: Intact, impaired, risky decisions.

Cognition

• Alertness: Alert, drowsy, lethargic.
• Orientation: Person, place, time, situation.
• Attention & Memory: Intact, distracted, impaired recall.
• Language & Problem Solving: Intact, impaired abstraction.

Impulse Control

• Regulation: Normal, poor, aggressive, reckless.
• Examples: Outbursts, self-harm.

Risk Assessment

• Suicidal/Homicidal Ideation: None, passive, active, plan.
• Self-Harm: Present, absent, history.
• Violence Risk: Low, moderate, high.