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Practice name: ______________________________
Mental Status Examination (MSE)
Your information
Full Name *
Presenting Complaint
Appearance & Behavior
Psychomotor Activity
Speech Characteristics
Mood (Patient Report)
Affect (Observed)
Additional details
Thought Process
Thought Content
Perceptual Disturbances
Cognition (Orientation/Memory)
Clinical Impression
Examiner Signature
Date
Mental Status Examination (MSE) template from formisoft.com. formisoft.com/intake-templates/mental-status-exam