-description of client's clothes and self-care
-striking characteristics (scars, tattoos, etc should be noted)
-whether the client looks older/younger than stated age
-eye contact
-peculiar mannerisms
-whether client appears to be responding to internal stimuli
-motor behavior-restless, agitated, subdued, shaking, tremulous, rigid, pacing, withdrawn
-attitude toward the interview
-speech rate, volume, tone of voice
-describe thought process
" Pressured speech (increased rate of speech)
" Tangential thought (some connections between preceding thought and next statement)
" Circumstantial thought (same as above but returns to original topic)
" Loosening of associations (thoughts appear unconnected at times)
" Word salad (extreme loosening of associations)
" Flight of ideas (tangential thought or loosening of associations and pressured speech)
" Though blocking (stop in mid-sentence and never return to original idea)
" Illogical thought (displays illogical conclusions)
-ruminations (preoccupation with worries and feelings of guilt; thinking process does not appear strange to the client and they do not attempt to stop; too caught up in the process)
-obsessions (specific thought repeated over and over; client find this odd and painful; frequently attempt to stop the process)
-delusions (strongly held beliefs that are not correct or held to be true by vast majority of client's culture)
-presence of suicidal or homicidal ideation (presence of suicidal/homicidal wishes, plans, and degree of intent to follow the plans in an immediate sense)
-refers to the presence or absence of hallucinations or illusions
-visual, auditory, tactile
-mood-a self-report symptom of how he or she has been feeling recently; persistent
-affect-a physical sign of the client's mood (demonstrated by facial expressions and other nonverbal expressions); transient
-terms used to describe affect: normal (broad) affect with full range of expression; restricted affect (some decrease in facial animation); blunted affect (a fairly striking decrease in facial expression); flat affect (no sign of spontaneous facial activity); buoyant affect; angry affect; suspicious affect; frightened affect; flirtatious affect; silly affect; threatening affect; labile affect; edgy affect
-basic level of functioning with regard to the level of consciousness, intellectual functioning, insight, and motivation
-always note whether the client exhibited a normal level of consciousness (awake, alert)
-Informal cognitive exam: performed throughout the interview in an non-invasive way (notes concentration and memory throughout the process of questioning)
-Formal cognitive exam: can range form a brief survey pf orientation, digit spans, and short-term memory, to a much more comprehensive exam lasting about 20 minutes or so