DASS 21

First Name

Last Name

DOB

Date

Email Address

1. I found it hard to wind down *

0 - NEVER1 - SOMETIMES 2 - OFTEN 3 - ALMOST ALWAYS

2. I was aware of dryness of my mouth *

0 - NEVER1 - SOMETIMES 2 - OFTEN 3 - ALMOST ALWAYS

3. I couldn’t seem to experience any positive feeling at all *

0 - NEVER1 - SOMETIMES 2 - OFTEN 3 - ALMOST ALWAYS

4. I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion) *

0 - NEVER1 - SOMETIMES 2 - OFTEN 3 - ALMOST ALWAYS

5. I found it difficult to work up the initiative to do things *

0 - NEVER1 - SOMETIMES 2 - OFTEN 3 - ALMOST ALWAYS

6. I tended to over-react to situations *

0 - NEVER1 - SOMETIMES 2 - OFTEN 3 - ALMOST ALWAYS

7. I experienced trembling (eg, in the hands) *

0 - NEVER1 - SOMETIMES 2 - OFTEN 3 - ALMOST ALWAYS

8. I felt that I was using a lot of nervous energy *

0 - NEVER1 - SOMETIMES 2 - OFTEN 3 - ALMOST ALWAYS

9. I was worried about situations in which I might panic and make a fool of myself *

0 - NEVER1 - SOMETIMES 2 - OFTEN 3 - ALMOST ALWAYS

10. I felt that I had nothing to look forward to *

0 - NEVER1 - SOMETIMES 2 - OFTEN 3 - ALMOST ALWAYS

11. I found myself getting agitated *

0 - NEVER1 - SOMETIMES 2 - OFTEN 3 - ALMOST ALWAYS

12. I found it difficult to relax *

0 - NEVER1 - SOMETIMES 2 - OFTEN 3 - ALMOST ALWAYS

13. I felt down-hearted and blue *

0 - NEVER1 - SOMETIMES 2 - OFTEN 3 - ALMOST ALWAYS

14. I was intolerant of anything that kept me from getting on with what I was doing *

0 - NEVER1 - SOMETIMES 2 - OFTEN 3 - ALMOST ALWAYS

15. I felt I was close to panic *

0 - NEVER1 - SOMETIMES 2 - OFTEN 3 - ALMOST ALWAYS

16. I was unable to become enthusiastic about anything *

0 - NEVER1 - SOMETIMES 2 - OFTEN 3 - ALMOST ALWAYS

17. I felt I wasn’t worth much as a person *

0 - NEVER1 - SOMETIMES 2 - OFTEN 3 - ALMOST ALWAYS

18. I felt that I was rather touchy *

0 - NEVER1 - SOMETIMES 2 - OFTEN 3 - ALMOST ALWAYS

19. I was aware of the action of my heart in the absence of physicalexertion (eg, sense of heart rate increase, heart missing a beat) *

0 - NEVER1 - SOMETIMES 2 - OFTEN 3 - ALMOST ALWAYS

20. I felt scared without any good reason *

0 - NEVER1 - SOMETIMES 2 - OFTEN 3 - ALMOST ALWAYS

21. I felt that life was meaningless *

0 - NEVER1 - SOMETIMES 2 - OFTEN 3 - ALMOST ALWAYS

Synergy Clinical Services

3/24 Brown Road, Broadmeadow NSW 2292

Ph (02) 4072 1868

Fax (02) 7234 0505

www.synergyclinicalservices.com.au