Appearance: How does the patient look? Neatly dressed with clear attention to detail? Well groomed?
Level of alertness: Is the patient conscious? If not, can they be aroused? Can they remain focused on your questions and conversation? What is their attention span?
Speech: Is it normal in tone, volume and quantity?
Behavior: Pleasant? Cooperative? Agitated? Appropriate for the particular situation?
Awareness of environment/orientation: Do they know where they are and what they are doing here? Do they know who you are? Can they tell you the day, date and year?
Mood: How do they feel? (e.g. “Are you happy, sad, depressed, angry?”). Is it appropriate for their current situation?
Affect: How do they appear to you? Do they make eye contact? Are they excitable? Does the tone of their voice change? Common assessments include: flat (unchanging throughout), excitable, appropriate.
Thought Process: This is a description of the way in which they think. Are their comments logical and presented in an organized fashion? If not, how off base are they? Do they tend to stray quickly to related topics? Are their thoughts appropriately linked or simply all over the map?
Thought Content: A description of what the patient is thinking about. Are they paranoid? Delusional (i.e. hold beliefs that are untrue)? If so, about what? Phobic? Hallucinating (you need to ask if they see or hear things that others do not)? Fixated on a single idea? If so, about what. Is the thought content consistent with their affect? If there is any concern regarding possible interest in committing suicide or homicide, including a search for details (e.g. specific plan, time etc.)