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Geriatric Depression Scale (Short Form) (301833-DT)

Geriatric Depression Scale (Short Form) (301833-DT) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Patient Name

DOB:

MR #

Index to Questionnaire - Health/Encounter


UWH# 301833-DT (Rev. 06/06/16) GERIATRIC DEPRESSION SCALE (SHORT FORM)
Page 1 of 2
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
GERIATRIC DEPRESSION SCALE
(SHORT FORM)







Date: ___________________________

Instructions: Choose the best answer for how you felt over the past week. Note: when asking the
patient to complete the form, provide the self-rated form (included on the following page).

No.
Question
Answer Score
1. Are you basically satisfied with your life? Yes/No
2. Have you dropped many of your activities and interests? Yes/No
3. Do you feel that your life is empty? Yes/No
4. Do you often get bored? Yes/No
5. Are you in good spirits most of the time? Yes/No
6. Are you afraid that something bad is going to happen to you? Yes/No
7. Do you feel happy most of the time? Yes/No
8. Do you often feel helpless? Yes/No
9. Do you prefer to stay at home, rather than going out and doing new things? Yes/No
10. Do you feel you have more problems with memory than most people? Yes/No
11. Do you think it is wonderful to be alive? Yes/No
12. Do you feel pretty worthless the way you are now? Yes/No
13. Do you feel full of energy? Yes/No
14. Do you feel that your situation is hopeless? Yes/No
15. Do you think that most people are better off than you are? Yes/No
TOTAL
(Sheikh & Yesavage, 1986)


Scoring:
Answers indicating depression are in bold and italicized; score one point for each one selected. A score of 0 to 5 is normal. A score
greater than 5 suggests depression.


Sources:
• Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol.
1986 June; 5(1/2):165-173.
• Yesavage JA. Geriatric Depression Scale. Psychopharmacol Bull. 1988; 24(4):7090711.
• Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report.
J Psychiatr Res. 1982-83; 17(1):37-49.


Patient Name

DOB:

MR #

Index to Questionnaire - Health/Encounter

UWH# 301833-DT (Rev. 06/06/16) GERIATRIC DEPRESSION SCALE (SHORT FORM)
Page 2 of 2
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
GERIATRIC DEPRESSION SCALE
(SHORT FORM) SELF –RATED VERSION









Instructions: Choose the best answer for how you felt over the past week.


No. Question Answer Score
1. Are you basically satisfied with your life? Yes/No
2. Have you dropped many of your activities and interests? Yes/No
3. Do you feel that your life is empty? Yes/No
4. Do you often get bored? Yes/No
5. Are you in good spirits most of the time? Yes/No
6. Are you afraid that something bad is going to happen to you? Yes/No
7. Do you feel happy most of the time? Yes/No
8. Do you often feel helpless? Yes/No
9. Do you prefer to stay at home, rather than going out and doing new things? Yes/No
10. Do you feel you have more problems with memory than most people? Yes/No
11. Do you think it is wonderful to be alive? Yes/No
12. Do you feel pretty worthless the way you are now? Yes/No
13. Do you feel full of energy? Yes/No
14. Do you feel that your situation is hopeless? Yes/No
15. Do you think that most people are better off than you are? Yes/No
TOTAL
(Sheikh & Yesavage, 1986)










Signature of Patient/Representative _________________________________Date: __________ Time: __________AM/PM


If signed by person other than the patient, print name and state relationship and authority to do so.


Print Name: _____________________________________Relationship: __________________________________

Patient is:  Minor  Incompetent / Incapacitated
Legal Authority:  Legal Guardian  Parent of Minor  Health Care Agent  Other _____________________


Reviewed by: ___________________________________________________ Date: ______________ Time: __________ AM/PM