Component	Definition/content	What to assess	Sample questions/tests	Potential diagnoses if abnormal
General observations
Appearance and behavior	Body habitus, eye contact, interpersonal style, style of dress	Appearance: attention to detail, attire, distinguishing features (e.g., scars, tattoos), grooming, hygiene	NA	Disheveled: depression, schizophrenia/psychotic disorder, substance use
		Behavior: candid, congenial, cooperative, defensive, engaging, guarded, hostile, irritable, open, relaxed, resistant, shy, withdrawn		Irritable: anxiety
		Eye contact: fleeting, good, none, sporadic		Paranoid: psychotic disorder
				Poor eye contact: depression, psychotic disorder
				Provocative: personality disorder or trait
Mood and affect	Mood: subjective report of emotional state by patient	Body movements/making contact with others, facial expressions (tearfulness, smiles, frowns)	How is your mood?	Mood disorder, schizophrenia, substance use
	Affect: objective observation of patient's emotional state by the physician		Have you felt sad/discouraged lately?
			Have you felt energized/out of control lately?
Motor activity	Facial expressions, movements, posture	Akathisia: excessive motor activity (e.g., pacing, wringing of hands, inability to sit still)	NA	Akathisia: anxiety, drug overdose or withdrawal, medication effect, mood disorder, parkinsonism, posttraumatic stress disorder, schizophrenia
		Bradykinesia: psychomotor retardation (e.g., slowing of physical and emotional reactions)		Bradykinesia: depression, medication effect, schizophrenia
		Catatonia: immobility with muscular rigidity or inflexibility		Catatonia: schizophrenia/psychotic disorder, severe depression
Cognitive functioning
Attention	Ability to focus based on internal or external priorities	—	Count by sevens or fives	Attention-deficit/hyperactivity disorder, delirium, dementia, mood disorder, psychotic disorder
			Spell a word backwards
Executive functioning	Ordering and implementation of cognitive functions necessary to engage in appropriate behaviors	Testing each cognitive function involved in completing a task	Clock drawing test: ask patient to draw a clock with hands set to 11:10	Delirium, dementia, mood disorder, psychotic disorder, stroke
			Trail-making test: ask patient to alternate numbers with letters in ascending order (e.g., A1B2C3)
Gnosia	Ability to name objects and their function	—	Show patient a common object (e.g., pen, watch, cellular telephone) and ask if he or she can identify it and describe how it is used	Advanced dementia, stroke
Language	Verbal or written communication	Appropriateness of conversation, rate of speech (> 100 words per minute is normal; < 50 words per minute is abnormal), reading and writing appropriate to education level	NA	Rapid or pressured speech: mania
				Slow or impoverished speech: delirium, depression, schizophrenia
				Inappropriate conversation: personality disorder, schizophrenia
				Inappropriate reading/writing level: dementia, depression, previous stroke
Memory	Recall of past events	Declarative: recall of recent and past events	When is your birthday?	Short-term deficit: amotivation, attention-deficit/hyperactivity disorder, dementia, inattention, substance use
		Procedural: ability to complete learned tasks without conscious thought	What are your parents' names?	Long-term deficit: advanced dementia, amnesia, dissociative disorder, movement disorder, previous stroke
			Where were you born?
			Where were you on September 11, 2001?
			Ask patient to repeat three words immediately and again in five minutes
			Ask patient to sign his/her name while answering unrelated questions (each test must be tailored to the individual patient)
Orientation	Ability of patient to recognize his or her place in time and space	Time, space, person	What year/month/day/time is it?	Amnesia, delirium, dementia, mania, previous stroke, severe depression
			What city/building/floor/room are you in?
			What is your name? When were you born?
Praxis	Ability to carry out intentional motor acts	Apraxia: inability to carry out motor acts; deficits may exist in motor or sensory systems, comprehension, or cooperation	Could you show me how to use this hairbrush/hammer/pencil?	Delirium, dementia, intoxication, stroke
Prosody	Ability to recognize the emotional aspects of language	—	Repeat “Why are you here?” with multiple inflections (e.g., happy, surprised, excited, angry, sad) and ask patient to identify the emotion	Autism spectrum disorder, developmental delay, mood disorder, schizophrenia
			Ask the patient to say the same sentence with each of the above emotional inflections
Thought content	What the patient is thinking	Delusions, hallucinations, homicidality, obsessions, phobias, suicidality	Do you have thoughts or images in your head that you cannot get out?	Delusions: fixed delusions, mania, psychotic disorder/psychotic depression
			Do you have any irrational or excessive fears?	Hallucinations: delirium, dementia, mania, schizophrenia, severe depression, substance use
			Do you think people are trying to hurt you in some way?	Homicidality: mood disorder, personality disorder, psychotic disorder
			Are people talking behind your back?	Obsessions: obsessive-compulsive disorder, posttraumatic stress disorder, psychotic disorder
			Do you think people are stealing from you?	Phobias: anxiety disorder, posttraumatic stress disorder
			Do you feel life is not worth living?	Suicidality: depression, posttraumatic stress disorder, substance use
			Do you see things that upset you?
			Do you ever see/hear/smell/taste/feel things that are not really there?
			Have you ever heard or seen something other people have not?
			Have you ever thought about hurting others or getting even with someone who wronged you?
			Have you ever thought about hurting yourself? If so, how would you do it?
			Have you ever thought the world would be better off without you?
Thought processes	Organization of thoughts in a goal-oriented pattern	Circumferential: patient goes through multiple related thoughts before arriving at the answer to a question	Generally apparent throughout the encounter	Anxiety, delirium, dementia, depression, schizophrenia, substance use
		Disorganized thoughts: patient moves from one topic to another without organization or coherence
		Tangential: patient listens to question and begins discussing related thoughts, but never arrives at the answer
Visuospatial proficiency	Ability to perceive and manipulate objects and shapes in space	—	Ask patient to copy intersecting pentagons or a three-dimensional cube on paper	Delirium, dementia, stroke
			Draw a triangle and ask patient to draw the same shape upside down