Adult history & MSE checklist

An original clinician working sheet. Document observations, patient accounts and clinical uncertainty in your own words.

A review marker records that a topic was addressed; it does not imply a normal finding. Avoid identifiers. This sheet does not create a signed clinical record or replace an appropriate record system.

Presenting concerns and goals
Current episode and lifetime course
Self-harm, suicide, violence and vulnerability
Substances and medicines
Medical and neurological history
Personal, family and social context
MSE: appearance, behaviour and engagement
MSE: speech, mood and affect
MSE: thought and perception
MSE: cognition, insight and judgement
Clinician formulation and differential
Agreed plan and follow-up

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Reference information · Educational reference
Last content update
2026-10-26
Clinical review
Not independently reviewed
Source jurisdiction
See individual sources
Coverage
Educational reference
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