Mental Health Assessment Form

Guides a clinician through a mental status exam, from the patient's personal details to diagnosis and treatment. It records appearance, behaviour, cognition, medical background and medication.

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In the Claude connectors directory

Patient details

Patient ID

Full name

First Name

Last Name

Nickname

Age

Date of birth

Gender

Female Male Non-binary Prefer not to say

Phone number

Address

Street Address

City

State / Province

ZIP / Postal Code

Employment status

Emergency contact

First Name

Last Name

Emergency contact phone

Assessment start (date and time)

Assessment end (date and time)

Main concern (symptoms, duration, intensity)

Family and interpersonal relationships (describe how the patient relates to others)

General appearance

Well groomed Disheveled Inappropriate Bizarre

Motor activity

Normal Restless Agitated Slowed

Judgment

Good Fair Poor

Memory

Intact Mildly impaired Impaired

Concentration

Good Easily distracted Poor

Insight

Good Partial None

Cognition

Normal Mildly impaired Severely impaired

Speech

Normal Pressured Slow Slurred

Affect

Appropriate Flat Labile Anxious

Daily patterns

Regular Disrupted sleep Appetite changes Withdrawn

Any current or past violent behaviour? If yes, explain when, how and what happened.

Does the patient have any past or current medical condition to declare (head injury, accident, etc.)?

Any previous hospitalizations? If yes, give the reason.

Does the patient have any allergies? If yes, list them.

Is the patient currently taking any medication? If yes, list it.

Mental health diagnosis

Treatment plan

Healthcare worker name

First Name

Last Name

Position / title

Healthcare worker signature

Sign here

Date signed

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