Nursing Mental Health Assessment Form

Mental Health Assessment Form

• Designed for patients to provide personal and medical information to assess their mental health
• Divided into sections: Demographic Profile, Psychosocial Assessment, Family History and Social History, Relationships, Substance Use History, Spiritual and Cultural Assessment, Violence Risk Assessment, Coping Skills, Interests and Abilities, and Mental Status Checklist

Demographic Profile

• Collects personal information: full name, nickname, age, sex, date of birth, address, email, contact number, city/town, province, postal code, marital status, occupation, ethnicity, religion, health insurance/health card number, and emergency contact details

Psychosocial Assessment

• Evaluates the patient's chief concerns, psychiatric history, and current mood
• Asks about previous counseling sessions, hospitalizations, and feelings
• Inquires about the patient's mood, including feelings of anxiety, depression, or suicidal thoughts

Family History and Social History

• Explores the patient's family dynamics, childhood, and relationships with parents, siblings, and guardians
• Inquires about family history of mental illness, substance abuse, and cultural or social issues that impacted childhood
• Examines the patient's current relationships with family members and siblings

Relationships

• Assesses the patient's marital history, including duration and quality of marriages
• Evaluates the patient's relationships with their spouse, children, and other family members

Substance Use History

• Inquires about the patient's history of substance use, including type, frequency, and last use of various substances

Spiritual and Cultural Assessment

• Explores the patient's religious faith, spiritual beliefs, and cultural practices
• Evaluates the role of spirituality in the patient's life and treatment

Violence Risk Assessment

• Assesses the patient's risk of harming themselves or others
• Inquires about suicidal thoughts, previous suicide attempts, and harm to others

Coping Skills

• Evaluates the patient's coping mechanisms and strategies
• Inquires about the patient's hobbies, interests, strengths, and weaknesses

Interests and Abilities

• Explores the patient's leisure activities, skills, and personal strengths and weaknesses

Mental Status Checklist

• Assesses the patient's appearance, behavior, speech, and thought processes
• Evaluates the patient's level of consciousness, orientation, and cognitive function### Speech
• Quantity: Talkative, expansive, paucity, poverty
• Fluency: Slurred, clear, hesitant, with good articulation
• Language: Neologisms, anomia, word salad, clang associations, echolalia, apraxia, aphasia

Mood and Affect

• Mood: Subjective, angry, irritable, restricted, depressed, guilty, brightly elevated, darkly elevated, other
• Affect: Objective, appropriate, inappropriate, blunted, broad, flat, restricted, labile, constricted, apathetic, congruent

Physiologic and Self-Care Considerations

• Eating habits and behaviors: Normal, emotional under-eating, emotional overeating
• Sleep: Average hours of sleep, sleep patterns (normal, difficulty falling asleep, staying asleep, waking up too early, unrefreshing/non-restorative, nightmares)
• Limitations in performing ADL: Washing, toileting, dressing, feeding, mobility, transferring

Memory

• Immediate Memory: Average, below average, no data
• Recent Memory: Average, below average, no data
• Remote Memory: Average, below average, no data
• Questions to assess memory:
  • Immediate memory: Ask client to remember three words and repeat them after 5 minutes
  • Recent memory: Ask client about examiner's name, medications taken, recent events
  • Remote memory: Ask client about childhood or past history, favorite childhood memory, year of finishing studies

Insight

• Can recognize one's strengths and limitations: Good, fair, poor
• Can recognize illness and need for treatment: Good, fair, poor
• Questions to assess insight:
  • Can you recognize your strengths and weaknesses?
  • Do you think you need treatment?

Judgment

• Good, fair, poor
• Questions to assess judgment:
  • If you found a wallet on the floor, what would you do?
  • If you were in a situation where you had to make a decision, what would you do?

Suicidal and Homicidal Ideation

• Suicidality: None, ideation, plan, intent, self-harm
• Homicidality: None, ideation, plan, intent
• Questions to assess suicidality and homicidality:
  • Do you ever feel like life isn't worth living?
  • Have you ever thought of harming yourself or others?
  • Do you think about hurting others who have wronged you?

Thought Process

• Overabundance, paucity, spontaneity, goal-directed, logical, perceptive, perseveration or repetition of thoughts, tangential, loose associations, rambling

Thought Content

• Obsessions, compulsions, phobias, paranoia, persecution, wanting to harm self or others, somatic concerns, repetitive thoughts of worry
• Questions to assess thought content:
  • What's been on your mind lately?
  • Have you had any recent obsessions or phobias?
  • Do you have any worries about being sick?

Thought Disturbances

• Delusions (false beliefs), hallucinations, ideas of reference, thought broadcasting, magical thinking, grandiosity, confabulation
• Questions to assess thought disturbances:
  • Do you have any personal beliefs that are not shared by others?
  • Do you sometimes feel like things are unnatural or unreal?
  • Do you hear voices or see things that are not really there?

Attention

• Attention/distractibility: Sufficient, deficient, easily distractible, short attention span

• Questions to assess attention:

  • Repeat the days of the week backwards
  • Spell the word "hotdog" backwards### Intellectual Abilities

• Ability to concentrate involves sustained, selected, and divided attention

• Intellectual abilities can be measured through information and vocabulary tests

Information and Vocabulary

• Information tests assess knowledge of current events, such as:
  • Naming the current president, vice president, and mayor
  • Identifying cities located in Cavite
• Vocabulary tests evaluate language proficiency at different levels:
  • Grade school level
  • High school level
  • Fluent
  • Consistent with education

Abstraction

• Abstraction involves identifying similarities and understanding proverbs
• Similarities test:
  • Identifying commonalities between objects, such as:
    • Apple and orange
    • Chair and table
• Proverbs test:
  • Understanding the meaning of sayings, such as:
    • "Ang hindi lumingon sa pinanggalingan, ay di makakarating sa paroroonan"
    • "Kapag binato ka ng bato, batuhin mo ng tinapay"
    • "Pag may tiyaga, may nilaga"