Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Geriatric Depression Scale (GDS) Form
Your information
Patient Name *
Date of Birth
____ / ____ / ________
Date of Screening
____ / ____ / ________
Satisfied with Life
Dropped Activities and Interests
Feel Life is Empty
Often Get Bored
In Good Spirits Most of the Time
Additional details
Afraid Something Bad Will Happen
Feel Helpless
Prefer Staying Home
Memory Problems
Current Medications
| Medication | Dose | How often |
|---|---|---|
GDS Total Score
Provider Notes
Geriatric Depression Scale (GDS) Form template from formisoft.com. formisoft.com/intake-templates/geriatric-depression-screening