Record every score in your template.
Vero Scribe writes scores, findings, and plans into the templates you choose, from the visit or your dictation, in 60+ languages. You review every line before it goes into your record.
Clinical screening tools and scales
The scores you use every day: what each one measures, what the numbers mean, and how to record them. Score the free tools as you answer; for the rest, see the bands and get the official form from its source.
- 51 tools, 12 scored on the page
- Score bands explained
- Recording templates to copy
Mental health
PHQ-9: Patient Health Questionnaire-9
Nine questions on the last two weeks: depression screening and severity, scored 0 to 27. Scores on the page.PHQ-2: Patient Health Questionnaire-2
Two questions on interest and mood: a quick first screen for depression, scored 0 to 6. Scores on the page.GAD-7: Generalized Anxiety Disorder-7
Seven questions on worry and tension: anxiety screening and severity, scored 0 to 21. Scores on the page.C-SSRS: Columbia Suicide Severity Rating Scale
Up to six questions on suicidal thoughts and behavior; the highest yes sets low, moderate, or high risk.PCL-5: PTSD Checklist for DSM-5
Twenty items on the past month: PTSD screening and symptom tracking, scored 0 to 80. Scores on the page.EPDS: Edinburgh Postnatal Depression Scale
Ten self-report items on the past 7 days: depression screening in pregnancy and after birth, scored 0 to 30.GDS-15: Geriatric Depression Scale, short form
Fifteen yes or no questions on the past week: a depression screen built for older adults, scored 0 to 15. Scores on the page.HAM-D: Hamilton Depression Rating Scale
Clinician-rated from an interview: depression severity and change with treatment, scored 0 to 52 on the 17-item version.HAM-A: Hamilton Anxiety Rating Scale
Fourteen items rated by a clinician in an interview: how severe anxiety is, psychic and somatic, scored 0 to 56.YMRS: Young Mania Rating Scale
Clinician-rated from an interview and observation: how severe mania is now, 11 items scored 0 to 60.MDQ: Mood Disorder Questionnaire
Self-report screen for past mania or hypomania: 13 yes-or-no symptoms and two follow-up questions, positive on a three-part rule.ACE questionnaire: Adverse Childhood Experiences questionnaire
Ten kinds of childhood abuse, neglect, and household challenges: a count of exposure, scored 0 to 10.Alcohol and substance use
AUDIT-C: Alcohol Use Disorders Identification Test-Concise
Three questions on how often and how much someone drinks, scored 0 to 12: positive at 4 or more for men, 3 or more for women. Scores on the page.AUDIT: Alcohol Use Disorders Identification Test
The WHO’s 10 questions on drinking, dependence, and harm, scored 0 to 40 into four zones that each come with an intervention. Scores on the page.CAGE: CAGE questionnaire
Four yes-or-no questions on drinking problems at any point in life: positive at 2 or more of 4.CIWA-Ar: Clinical Institute Withdrawal Assessment for Alcohol, revised
Ten signs rated at the bedside: how severe alcohol withdrawal is now, scored 0 to 67.COWS: Clinical Opiate Withdrawal Scale
Eleven withdrawal signs, from pulse to gooseflesh, rated by a clinician: opioid withdrawal severity from 0 to 48.CRAFFT 2.1: CRAFFT 2.1 adolescent substance use screen
A teen alcohol and drug screen for ages 12 to 21: days of use, then six yes-or-no questions scored 0 to 6, high risk at 2 or more.Neurology and stroke
Cognition and attention
ASRS v1.1: Adult ADHD Self-Report Scale
Six self-report questions on the past six months: a positive adult ADHD screen at 4 or more of 6 shaded answers.SLUMS: Saint Louis University Mental Status Examination
Eleven items on memory, attention, and executive function: a cognitive screen scored 0 to 30, with cutoffs set by schooling.Mini-Cog: Mini-Cog
Three-word recall and a clock drawing in about 3 minutes: a dementia screen scored 0 to 5, positive at 0 to 2.MoCA: Montreal Cognitive Assessment
Memory, attention, language, visuospatial and executive skills, and orientation in about 10 minutes: scored 0 to 30, normal at 26 or more.Children and development
M-CHAT-R/F: Modified Checklist for Autism in Toddlers, Revised with Follow-Up
A 20-question parent checklist that screens toddlers for autism from 16 to 30 months, scored 0 to 20, with a Follow-Up interview.Vanderbilt: NICHQ Vanderbilt Assessment Scales
Parent and teacher ADHD rating forms for ages 6 to 12: six of nine symptoms in a domain, with impaired performance, meets the count.PHQ-A: Patient Health Questionnaire for Adolescents
The PHQ-9 modified for teens 11 to 17: nine symptoms scored 0 to 27, plus a past-year question and two suicide questions.SNAP-IV: SNAP-IV 26-item rating scale (Swanson, Nolan and Pelham)
A 26-item parent and teacher rating of ADHD and oppositional symptoms, scored as subscale averages from 0 to 3.SCARED: Screen for Child Anxiety Related Emotional Disorders
A 41-item child and parent anxiety screen for ages 8 to 18: total 0 to 82, cutoff 25, with five subscales.Sleep
ESS: Epworth Sleepiness Scale
Eight everyday situations rated for the chance of dozing: daytime sleepiness scored 0 to 24, with above 10 excessive.STOP-Bang: STOP-Bang questionnaire for obstructive sleep apnea
Eight yes-or-no criteria for obstructive sleep apnea risk, before surgery and in clinic: scored 0 to 8, with 5 or more high risk.Nursing and skin
Function and pain
PROMIS: Patient-Reported Outcomes Measurement Information System
Patient-reported measures of symptoms and function, scored as T-scores with 50 as the average: short forms, CATs, and the PROMIS-29.Katz ADL: Katz Index of Independence in Activities of Daily Living
Six basic self-care activities rated independent or dependent, scored 0 to 6, for function and care needs in older adults.Lawton IADL: Lawton Instrumental Activities of Daily Living Scale
Eight independent living tasks, from shopping to finances, each scored 0 or 1: a total from 0, dependent, to 8, independent.QuickDASH: QuickDASH (Disabilities of the Arm, Shoulder and Hand)
Eleven questions on arm, shoulder, and hand function over the past week, scored 0 to 100: the higher, the more disability.LEFS: Lower Extremity Functional Scale
Twenty everyday activities rated for difficulty: lower limb function scored 0 to 80, higher is better, and 9 points is a real change.KOOS: Knee injury and Osteoarthritis Outcome Score
Forty-two questions on one knee over the past week: five subscales, each scored 0 to 100, where 100 means no knee problems.NDI: Neck Disability Index
Ten sections on how neck pain limits daily life, scored 0 to 50 or as a percentage: the higher, the more disability.ODI: Oswestry Disability Index
Ten sections on how low back pain limits daily life, scored as a percent from 0 to 100: the higher, the more disability.PSFS: Patient-Specific Functional Scale
The patient’s own activities, each rated 0 to 10: function scored as an average, compared only with the patient’s earlier ratings.BPI: Brief Pain Inventory
Pain severity and how much pain interferes with seven parts of daily life, each rated 0 to 10: reported as a severity score and a mean interference score.PEG: PEG 3-item pain scale (Pain, Enjoyment of life, General activity)
Three 0 to 10 ratings on the past week: pain, enjoyment of life, and general activity, averaged for a score from 0 to 10.Falls, frailty, and bone health
FRAX: Fracture Risk Assessment Tool
Ten-year probability of a major osteoporotic fracture and of a hip fracture, from 12 inputs, with or without bone density.Morse Fall Scale: Morse Fall Scale
Six nursing items that predict a patient’s risk of falling in hospital, scored 0 to 125: the higher the total, the higher the risk.TUG: Timed Up and Go test
Stand, walk 3 meters, turn, walk back, and sit: a timed test of mobility and fall risk, with 12 seconds as the usual flag. Scores on the page.Berg Balance Scale: Berg Balance Scale
Fourteen balance tasks, from sitting to standing on one leg, scored 0 to 56: the higher the total, the better the balance. Scores on the page.CFS: Clinical Frailty Scale
A 9-level clinical judgment of frailty in older adults, from very fit to terminally ill, scored on the person’s state before an acute illness.Edmonton Frail Scale: Edmonton Frail Scale
A scored frailty test across nine domains, with a clock drawing and a timed up and go, totaled 0 to 17 from not frail to severe frailty.Try Vero free
Frequently asked questions.
Are these screening tools free to use?
Each page says who holds the tool and how you may use it. Tools that may be reproduced, such as the PHQ-9 and the NIH Stroke Scale, are on the page in full and score as you answer. For tools that are copyrighted, the page links to the official form, and the recording template is free to copy or download.
Does a screening score make a diagnosis?
No. A screening tool flags who needs a closer look and measures change over time. The diagnosis comes from the clinical assessment, and each page explains what to check next.
How should I record a score in the chart?
Record the tool and version, who completed it and how, each item or domain score, the total and its band, any item that needs action on its own, the trend, and what you did. Each page has a template for exactly that.
Can Vero record scores for me?
Yes. Vero Scribe writes the result into your template from the visit, with the patient’s consent, or from your dictation, and you review and edit every line before it goes into your record.
Score it. Vero writes it up.
Vero records scores, findings, and plans in the templates you choose, so you review instead of type.
Try Vero free
No credit card required. 10 free actions every month.
Social needs
Hunger Vital Sign: Hunger Vital Sign food insecurity screen
Two statements on food running out in the past 12 months: positive if either is often or sometimes true. Scores on the page.AHC HRSN: Accountable Health Communities Health-Related Social Needs Screening Tool
CMS’s 10-question screen for five social needs: each domain scored on its own, counted here from 0 to 5.