GDS-15 GERIATRIC DEPRESSION SCREEN

Date: [Date]
Patient or resident: [Name or record number, age]
Where seen: [Home, clinic, memory clinic, long-term care home, or hospital ward]
Given by: [Name and role]

ADMINISTRATION
Version: [GDS-15 short form, or GDS-30 long form]
How given: [Self-completed on paper, read aloud word for word, or answered by pointing on a yes and no board]
Aids and language: [Hearing aids and glasses in use; language, translation, or interpreter]
Unanswered items: [None, or the item numbers and the prorated total, rounded up]

SCORE
GDS total: [0 to 15, or 0 to 30 on the long form]
Result: [Normal 0 to 4, mild 5 to 8, moderate 9 to 11, or severe 12 to 15]
Follow-up cutoff used: [5 or more, or above 5]
Items of note: [Depressed answers that stand out, such as worthless, hopeless, helpless, or not glad to be alive]

COGNITION AND HEALTH
Cognitive status: [Known diagnosis, latest cognitive screen and score, and whether every question was understood]
Physical health: [Pain, recent illness, falls, hospital stays, hearing or vision loss]
Medicines: [Sedating or mood-lowering medicines, and recent changes]
Losses and routine: [Bereavement, a move, lost role or driving, visitors, daily activities]

SAFETY
Thoughts of death or suicide: [Asked directly; the answer in their own words]
Means at home: [Firearms, stored medicines, or none]
Eating and self-care: [Intake, weight change, refusing care]

PLAN
Interview: [Done today with its findings, booked, or not needed]
Actions: [Activities and social contact, counseling, medication review or start, geriatric psychiatry referral]
Recheck: [Date or interval, same version]
Discussed with: [Patient, family, care team]

Clinician: [Name, credentials]