Mental Status Exam with Intake Interview

and Symptoms Checklist for Bipolar

Disorder

Prepared by:

ALMOJUELA, MARVE MAY D.

BACOLOD, KHAREN A.
CANTOR, JENNY VEL
C.
Mental Status Exam
Name: Date:
OBSERVATIONS
Appearance □ Neat □ Disheveled □ Inappropriate □ Bizarre □ Other
(please
describe):

Speech □ Normal □ Tangential □ □ Impoverished □ Other

Pressured (please
describe):

Eye Contact □ Normal □ Intense □ Avoidant □ Other

(please
describ
e)
Motor Activity □ Normal □ Restless □ □ Slowed □
Other Tics
(please
describe):
Affect □ Full □ Constricted □ □ Labile □ Other
Flat (please
describe):

Comments:

MOOD
□ Euthymic □ Anxious □ Angry □ Depressed □ Euphoric □ Irritable □ Other (please
describe):

Comments:
COGNITION
Orientation Impairment □ None □ Place □ Object □ Person □ Time
Memory Impairment □ None □ Short-Term □ Long-Term □ Other
(please
describe):
Attention □ Normal □ Distracted □ Other
(please
describe):
Comments:
PERCEPTION
Hallucinations □ None □ Auditory □ □
Other Visual please
describe):
Comments:
THOUGHTS
Suicidality □ None □ Ideation □ □ Intent □ Self-Harm
Plan
Homicidality □ None □ Aggressive □ □
Plan Intent

Delusions □ None □ Grandiose □ Paranoid □ Religious □ Other (please

 describe):

Comments:
BEHAVIOR
□ Cooperativ □ Gua □ Hyper □ Agitated □ Paranoid
e rded active □ □ Other (please
□ Stereotype □ □ Bizarr Withdra describe):
d Aggressi e wn
ve
Comments:

INSIGHT □ Goo □ Fair Comments:

d □ Poor
JUDGMENT □ Goo □ Fair Comments:
d □ Poor
 Bipolar Disorder

Checklist

Name:

Date:

Age:

Instructions: Please answer the following questions to the best of your ability. Choose the answer
that best describes your experience in the past two weeks.

Mood

1. Have you experienced any periods of feeling excessively happy, euphoric, or elated?

If yes, for how long?

How severe were these feelings?

1 2 3 4 5
(Not at all) (Mild) (Moderate) (Severe) (Very
Severe)
2. Have you experienced any periods of feeling excessively irritable, restless, or angry?

If yes, for how long?

How severe were these feelings?

1 2 3 4 5
(Not at all) (Mild) (Moderate) (Severe) (Very
Severe)
3. Have you experienced any periods of feeling sad, hopeless, or discouraged?

If yes, for how long?

How severe were these feelings?

1 2 3 4 5
(Not at all) (Mild) (Moderate) (Severe) (Very
Severe)

Energy

1. Have you experienced any periods of increased energy or activity?

If yes, for how long?

How severe was the increase in energy?

1 2 3 4 5
(Not at all) (Mild) (Moderate) (Severe) (Very
Severe)

2. Have you experienced any periods of decreased energy or fatigue?

If yes, for how long?

How severe was the decrease in energy?

1 2 3 4 5
(Not at all) (Mild) (Moderate) (Severe) (Very
Severe)
 Sleep

1. Have you experienced any difficulty falling asleep or staying asleep?

If yes, for how long?

How severe was the sleep disturbance?

1 2 3 4 5
(Not at all) (Mild) (Moderate) (Severe) (Very
Severe)

2. Have you experienced any changes in your sleep patterns, such as sleeping more
or less than usual?

If yes, for how long?

How severe was the change in sleep patterns?

1 2 3 4 5
(Not at all) (Mild) (Moderate) (Severe) (Very
Severe)

Behavior

1. Have you engaged in any impulsive or risky behaviors?

If yes, please provide examples:

2. Have you withdrawn from social activities or isolated yourself from others?

If yes, for how long?

How severe was the social withdrawal?

1 2 3 4 5
(Not at all) (Mild) (Moderate) (Severe) (Very
Severe)

3. Have you experienced any racing thoughts or difficulty concentrating?

If yes, for how long?

How severe were the racing thoughts or difficulty concentrating?

1 2 3 4 5
(Not at all) (Mild) (Moderate) (Severe) (Very
Severe)

Additional Symptoms

1. Have you experienced any difficulty making decisions or thinking clearly?

If yes, for how long?

How severe was the difficulty making decisions or thinking clearly?

1 2 3 4 5
(Not at all) (Mild) (Moderate) (Severe) (Very
Severe)
 Have you experienced any hallucinations or delusions?

If yes, please provide examples:

2. Have you experienced any changes in your appetite or weight?

If yes, for how long?

How severe were the changes in appetite or weight?

1 2 3 4 5
(Not at all) (Mild) (Moderate) (Severe) (Very
Severe)
 Bipolar Disorder Intake Interview
Demographic Information
Name: Date:
Address: Date of Birth:
Phone number: Age:
Insurance information:
• Insured
• Uninsured
Referred by: PCP: Dr.
• Releases signed Psychiatrist:
• Consent to treatment signed

Presenting Problem:
1. What brings you in for assessment today?

2. When did you first notice changes in your mood or energy levels?

3. Describe any recent episodes of feeling unusually high or low in mood.

Mood (self-reported):
● How are you feeling lately? Can you explain your mood last week?

● On a scale of 1 to 10, how would you evaluate your general mood today?

Affect (observed by clinician):

● How do you feel emotionally when you reflect on your recent experiences? What words would you use to describe that?

● Do you find yourself smiling or laughing less than you used to?

Mental Health History

1. Have you ever been diagnosed with a mental health condition before? If yes, what was the diagnosis and when?

2. Have you received any prior treatments, such as therapy or medications, for mood-related issues?

3. How often do you experience mood episodes, such as depressive or manic/hypomanic episodes?

4. Have you ever experienced suicidal thoughts or self-harming behaviors?

Medical History
1. Do you have any other medical conditions or chronic illnesses? If yes, what is it?

2. Are you currently taking any medications, including those unrelated to mental health?

3. Have you experienced any side effects from medications taken in the past?
Social History
1. How would you describe your relationships with family, friends, or significant others?

2. Are there any recent social stressors such as loss of a loved one and breakups that affecting you?

Legal History
1. Are there any legal responsibilities (such as probation) that could limit your access to mental health treatment?

Substance Use/ Abuse History

1. Do you currently use or have you ever used substances like alcohol, tobacco, or recreational drugs?

2. Does your family have a history of alcohol use or abuse? If yes, who in your family (parents, siblings, or extended
family) has struggled with alcohol use?

3. How has alcohol consumption in the family impacted your personal life (e.g., family connections, home environment)?

Additional information:
Is there anything else you want to share regarding your mental health or well-being?

What do you hope to gain from our sessions?