GENERAL APPEARANCE
Dress
Conventional: Customary; sanctioned by usage; traditional
Meticulous: Overly neat and clean, unusually careful of detail
Eccentric: Peculiar or unusual
Seductive: Inappropriate dressing to enhance sexual desirability
Disheveled: Untidy; rumpled; in disrepair; dirty
Grooming
Well-groomed: Clean and neat
Dirty: Hair, clothes and/or skin dirty
Unkempt: Hair not combed; buttons undone or incorrect
c. Hygiene
Good:
Fair:
Poor:
Facial Expression
Sad: Downcast and gloomy expression
Happy: Smiling; laughing
Angry: Frowning, scowling
Unremarkable: Lack of symptoms to arouse notice
Relaxed: Lack of tension; calm, loose muscles
Tense: Muscle taunt; showing emotional strain
Crying: Tearful
Suspicious: Looking around constantly as if worried about threat;
guarding information
Poor eye contact: Not meeting eyes of interviewer
Make-up
Not applicable: For men
Appropriate: Accenting client’s natural features appropriately
Not wearing: Absence
Peculiar/Bizarre: Heavy; exaggerated, or unnatural
Body
Wt./Ht. : Weight that is proportionate for height
Obese: Extremely fat or corpulent
Slender: Small in cross section compared to length
Emaciated: Extremely underweight
Speech
Audible/Inaudible: Loud enough to be heard by interviewer or not
Clear/Slurred: Distinct or indistinct
Pressured: Speaks very rapidly and continuously
Stammering: Uses involuntary halts, breaks and repetitions
Rapid/Slow:
Mumbling: Speaks in low tone and without articulation
Halting: Uses irregular rhythm
Garbled: Facts and sequence confused and mixed up
Incoherent: Disjointed and unintelligible
Even: Speech is smooth, steady, and constant
INTERVIEW BEHAVIOR
a. Attitude
Hostile: Angry, resentful or unfriendly
Euphoric: Demonstrates an exaggerated feeling of well-being
Threatening: Makes verbal or physical threats
Withdrawn: Avoids interpersonal interaction; stays to self
Defensive: Inappropriately defends against questions
Manipulative: Attempts to get own way using indirect means
Evasive: Avoids honest, overt, candid interaction
Passive: Does not initiate anything; accepts what’s offered
Dramatic/ Using theatrical appearance, speech and/or behavior
Grandiose:
Naive: Artless, shows lack of knowledge or experience for age
Aggressive: Overly assertive; insistent on getting own way
Negativistic: Says no to reasonable requests consistently
Overly cooperative: Excessive attempts to please
Ingratiating: Overly compliant to elicit favor and approval
Self Deprecating: Self-degrading; expresses feeling unworthy
Affectations: Posturing with artificial airs
Seductive: Flirtatious, sexual display; excessive intimacy
Disdainful: Superior attitude; disgust for others
Posture
Erect: Upright and straight
Slouched: drooping back and shoulders
Rigid: Stiff and inflexible; strongly resistant
Guarded: Appears to protect self from danger
Gait/Mobility
Steady: Walks without wavering
Even: Pace is at consistent rate
Limps: Gait is uneven due to weakness or deformity of limb
Shuffles: Walks while dragging feet instead of lifting them
Staggers: Swaying and uncertain gait
Level of Awareness
Attentive: Keeps mind on what is going on around them
Drowsy: Appears to want to go to sleep
Distractible: Distracted by environmental diversions
Inattentive: Unable to pay attention even briefly
Confused: Unable to distinguish between ideas; jumbled thoughts
Stuporous: Has some moments of unconsciousness
Hypervigilent: Heightened awareness of what goes on around them
ORIENTATION
Date and Time
Person
Place
Situation
4. MEMORY
Amnesia
Short term
Long term
AFFECT
Outward expression of feelings
Appropriate: Expressions suitable for situation
Angry: Displays passionate displeasure
Blunted: Appears insensitive, unperceptive, and slow to respond
Worried: Disturbed about specific event or outcome
Flat: Minimal expression with small or no range
Elevated: Unusually high spirits
Depressed: Unusually low spirits, dejected
Labile: Great variability of expression from moment to moment
Congruent: Non verbal and verbal expression of feelings match
6. THOUGHT PROCESSES
How the individual Thinks
Logical: Answers and thinking consistent with correct reasoning
Rambling: Wandering, disconnected thoughts
Incoherent: Disjointed and confused
Confabulation: Filling in memory gaps by guessing or making up
Blocking: Sudden stop in train of thought in the middle of thought
Circumstantial: Proceeding indirectly to goal idea with many tedious
details and irrelevant additions
Tangential: Thoughts veer from the main topic and never return to it
Perseveration: Persistent, involuntary repetition of a phrase or idea
Flight of Ideas: Continuous or rapid flow of speech that is not
disjointed or bizarre but which jumps from topic to topic
Loose Associations: Lack of logical relationship between thoughts or ideas
that follow each other
Indecision: Inability to make up one’s mind
Neologism: Coins new words that only the patient understands
Abstract: Avoids specificity, extremely theoretical orientation
Rhyming: Making words rhyme as in alliteration
Concretism: Inability to think in general terms
Fabrication: Create fictional fillers to bridge actual events
7. THOUGHT CONTENT
What the Individual Thinks About
Ideas of Failure: Focus on own lack of success
Impoverished: Very little thought content
Paranoia: Persistent, unrealistic belief that one is unsafe
Apathy: Absence of caring; indifferent
Phobias: Worries about a specific object or situation
Obsessions: Repetitive, unwanted ideas that intrude into thoughts
Ideas of Guilt: Focus on the belief that the patient acted in ways contrary to how he believes he should have acted
Ideas of
Hopelessness: Focus that there is no available prospect for happiness
Ideas of
Worthlessness: Constant belief that one is of no value
Somaticism: Focus on physical ailments or complaints
Thoughts of
Persecution: Believes others are planning to harm or interfere
Disassociation: Disconnection between thoughts, emotions and
sensations
Hallucinations
Auditory: Hearing things when there is no external stimulus
Visual: Seeing things when there is no external stimulus
Olfactory: Smelling odors with no actual basis
Tactile: Feeling touch sensation when there is no stimulus
Delusions
Persecution: Believing others are out to get him when there is no
realistic basis for fear
Grandeur: Unrealistic belief that one has unique and special status
or abilities
Thought
Broadcasting: Belief that one can read others’ minds
Reference: Believe that one is the topic or reference point for
conversations or activities going on around one
Influence: Belief that one’s thoughts or actions are controlled by
external forces or that one can control the thoughts
and actions of others.
INTELLECT
What is the Individual’s Level of Intellectual Functioning?
Functioning: Average, higher than average, below average
Inadequate
Fund of Knowledge: Individual lacks normal amount of general information
Retarded: Mental ability is markedly below average for age and
culture.
9. JUDGEMENT AND INSIGHT
Do the Individual’s Decisions and Behaviors Correlate to Reality?
Lacks Social Inability to evaluate situations and make sound
Judgment: decisions leading to appropriate and effective
actions when dealing with others
Lacks Personal Inability to evaluate situations and make
Judgment: decisions leading to appropriate and effective
actions for self.
Insight:
Excellent: Understands the severity of his illness, the need
For treatment, and some of the dynamics involved
Moderate: Knows why his is in treatment with some understanding
of what the problem is
Little or None: Does not know why he is in treatment
