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Healthcare GAD-7 and PHQ-9 Form

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Healthcare GAD-7 and PHQ-9 Form

Patient Information

Insurance Information

Medical History (brief)

Consent for Screening and Confidentiality

I understand that the GAD-7 and PHQ-9 are standardized screening tools used to assess symptoms of anxiety and depression. I authorize clinical staff to administer these screenings and to record the results in my medical record. Screening results are protected health information and will be handled in accordance with applicable privacy laws. Results may be used to guide clinical care, referrals, and, if necessary, safety planning.

I understand that screening does not replace a comprehensive diagnostic evaluation. If screening indicates significant risk to myself or others, including imminent risk of self-harm or harm to others, clinicians are required to take appropriate protective action which may include notifying emergency responders or family members.

GAD-7: Generalized Anxiety Disorder 7-item Scale

Over the last 2 weeks, how often have you been bothered by the following problems? For each item, select one response: Not at all (0), Several days (1), More than half the days (2), Nearly every day (3).

Interpretation guidance: 0–4 minimal, 5–9 mild, 10–14 moderate, 15–21 severe. Clinical judgment should guide any decisions regarding diagnosis, monitoring, or treatment. A score of 10 or greater suggests further assessment is warranted.

PHQ-9: Patient Health Questionnaire 9-item

Over the last 2 weeks, how often have you been bothered by the following problems? Responses: Not at all (0), Several days (1), More than half the days (2), Nearly every day (3).

Interpretation guidance: 0–4 minimal, 5–9 mild, 10–14 moderate, 15–19 moderately severe, 20–27 severe. Any positive response to item 9 requires immediate clinical evaluation for safety risk.

Risk and Safety Assessment

If you indicated any frequency greater than "Not at all" for item 9 on the PHQ-9, or if you have current thoughts of harming yourself or others, you will be contacted immediately for a safety assessment. Please answer the following:

Authorization and Release

I authorize the provider to review my screening responses and to include results in my health record. I further authorize the provider to share screening results with treating clinicians and, if necessary for safety, with designated emergency contacts or other appropriate parties. This authorization is voluntary and may be revoked in writing except to the extent action has been taken in reliance on it.

Patient Statement and Certification

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I understand the purposes, limits, and possible uses of the screening results. I understand that completion of these forms does not establish a provider-patient relationship beyond the scope of the clinical encounter in which they are used.

Patient Printed Name:

Signature:

Relationship to Patient (if signed by guardian):

Date:

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What the Healthcare GAD-7 and PHQ-9 Form Is

The Healthcare GAD-7 and PHQ-9 Form combines two validated screening tools: the Generalized Anxiety Disorder 7-item scale (GAD-7) and the Patient Health Questionnaire 9-item scale (PHQ-9). Clinicians use these brief questionnaires to screen for anxiety and depression symptoms, quantify severity using score totals, document baseline status, and support clinical decision-making and follow-up. These forms are commonly embedded in intake packets, primary care visits, behavioral health assessments, and telehealth workflows; they are screening instruments, not standalone diagnostic tools.

Why this combined screening form matters in clinical workflows

Using the combined GAD-7 and PHQ-9 standardizes screening, provides consistent numeric scores for monitoring over time, and creates a concise record for care coordination and billing documentation where appropriate.

Why this combined screening form matters in clinical workflows

Who completes and relies on the GAD-7 and PHQ-9 Form

Role-based ownership ensures the form is completed, scored, interpreted, and retained according to clinical policy and applicable privacy rules.

  • Primary care and family medicine clinicians screening routine visits and chronic disease management.
  • Behavioral health clinicians using scores to triage severity and guide treatment planning.
  • School health staff or occupational health teams screening populations for early intervention.

Typical professionals who authorize or act on results

Primary Care Clinician

Primary care physicians, nurse practitioners, and physician assistants commonly administer or review the form during visits to screen for mood and anxiety symptoms, determine need for further assessment, and coordinate referrals to behavioral health specialists.

Behavioral Health Clinician

Psychologists, licensed clinical social workers, and psychiatrists use the GAD-7 and PHQ-9 to quantify symptom severity, track treatment response across visits, and document clinical decisions in the patient record according to practice protocols.

Key components included in a professional GAD-7 and PHQ-9 Form

A compliant clinical screening form includes patient identifiers, the itemized questions for both scales, scoring guidance, clinician notes, and fields for consent and signature where required.

Patient ID

Full name, date of birth, medical record number, and visit date to ensure responses are associated unambiguously with the correct patient record and to support auditability.

GAD-7 Items

Seven standardized questions with the patient's frequency response options; include scoring instructions and automated or manual total calculation for severity categories.

PHQ-9 Items

Nine standardized questions with response choices and explicit scoring directions; include the suicidal ideation item and escalation pathway where positive.

Scoring Guide

Instructions for calculating totals, interpreting score ranges, and recommended clinical actions or referral thresholds aligned with practice policy.

Clinician Notes

Free-text area for assessment, plan, follow-up timing, safety planning, and documentation of informed consent for treatment or referral.

Consent & Signature

Patient consent statement, signature/date field, and optional caregiver signature fields when appropriate for minors or authorized representatives.

Step-by-step: completing the combined screening during patient intake

Follow these sequential steps to capture accurate responses, calculate scores, and route results for clinical review and documentation.

  • 01
    Provide form: Give patient digital or paper form before or at visit check-in.
  • 02
    Complete responses: Patient answers all items without skipping any questions.
  • 03
    Calculate totals: Sum each scale and record severity categories.
  • 04
    Document and act: Clinician reviews scores, documents plan, and initiates referrals if indicated.

How form submission and routing typically operate

Forms can be collected in person or remotely and then integrated into clinical workflows for scoring, clinician review, and retention in the health record.

  • Collect: Patient submits form at check-in or via secure portal.
  • Score: System auto-calculates totals or staff compute manually.
  • Review: Clinician examines scores and documents next steps.
  • Store: Completed form saved to EHR or secure document repository.

Configuring an online workflow for GAD-7/PHQ-9 collection

Set up fields, scoring, routing, and export rules to minimize manual steps and preserve an audit trail.

Field Configuration
Auto-score Enable automatic calculation and severity flagging.
Required fields Make all item responses mandatory to ensure valid totals.
Signer authentication Use patient portal login or SMS code for identity assurance.
Data export Map fields to EHR or CSV export for discrete storage.

Technical delivery options and supported formats

Ensure the selected system offers audit trails and the ability to enforce required fields and secure export to clinical records.

  • Formats: PDF, DOCX, HTML forms supported
  • Integrations: Salesforce, NetSuite, Microsoft 365, Google Workspace
  • Authentication: SMS codes, single sign-on, or portal credentials

Security, compliance and technical safeguards for patient screening data

HIPAA: BAA required for PHI handling
In-transit encryption: TLS 1.2 / 1.3
At-rest encryption: AES-256 encryption
Audit trail: Timestamped action logs
Authentication: Support for multi-factor options
Certifications: SOC 2 Type II and ISO 27001

Real-world examples of electronic screening in practice

Healthcare organizations and other teams have implemented digital intake forms and e-signature workflows to reduce friction and improve documentation.

Fertility Centers of Illinois

The practice integrated electronic forms into clinical workflows to capture patient-reported outcomes quickly

  • Quote used by organization to describe vendor support
  • "The airSlate SignNow team has been exceptional, responsive, the API has been great, and we're extremely happy that we chose airSlate SignNow as a company."

Optica Ventures LLC

An SMB example where simple digital forms improved customer interactions

  • Highlight on ease of use for both staff and external parties
  • "The interface is simple and easy-to-use for our team; more importantly, it is just as easy for our customers."

Common mistakes to avoid when preparing and collecting the form

  • Leaving items blank or marking multiple responses per question can invalidate the score and require recollection or clinician clarification.
  • Failing to document informed consent, especially for minors or telehealth, which may create compliance and liability exposure under HIPAA or FERPA.
  • Not escalating positive responses on the PHQ-9 suicide item immediately, delaying safety planning and required clinical intervention.
  • Storing completed forms in unsecured locations or without a BAA when using third-party services risks PHI exposure and regulatory penalties.

Risks and consequences of incorrect or noncompliant handling

HIPAA breach: Regulatory and civil exposure
Inaccurate scoring: Missed treatment needs
Missing consent: Liability and access restrictions
Unauthorized access: Data compromise risk
Retention failure: Noncompliance with record rules
Documentation gaps: Adverse legal outcomes

Practical tips for accurate, efficient completion and handling

Adopt simple operational controls to reduce errors, ensure privacy, and make scores actionable for clinical teams.

Obtain documented informed consent and access disclosure
Present a brief disclosure explaining electronic collection, storage, and the patient's right to paper records where required by 15 U.S.C. §7001 (ESIGN) and related consumer disclosure rules.
Use required fields and automated scoring
Configure digital forms to require all item responses and automatically calculate totals to eliminate manual arithmetic errors and speed clinical review.
Implement escalation workflows for risk items
Create built-in alerts when PHQ-9 suicide items are positive so clinicians receive immediate notification and a documented safety plan can be initiated.
Secure exports and EHR mapping
Map discrete fields to the EHR, retain audit logs, and ensure vendor BAAs for any external platform that handles PHI.

Sample eSignature vendor pricing and capability snapshot

Comparison of starting prices and common capabilities; signNow appears first per vendor ordering conventions. Verify vendor sites and plans for specific enterprise features and terms.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies Varies Varies Varies
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No envelope cap 100 envelopes/user/year Varies Varies Varies

Frequently asked questions and troubleshooting for the GAD-7 and PHQ-9 Form

Answers to common issues when collecting, scoring, or storing combined GAD-7 and PHQ-9 screening forms in clinical environments.


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