DASS-21 Form

Date

DayMonthYear

Full Name

First NameLast Name

Date of Birth

Date

Phone Number

Area CodePhone Number

Email

example@example.com

Dass 21

The DASS-21 (Depression, Anxiety and Stress Scale - 21 items) is a short self-report questionnaire designed to measure symptoms of depression, anxiety, and stress over the past week. It helps identify emotional patterns and track changes over time. While it’s not a diagnostic tool, it can support understanding of how you're feeling and guide further conversations with a health professional.

Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you "over the past week". There are no right or wrong answers. Do not spend too much time on any statement.

The rating scale is as follows:

0 Did not apply to me at all

1 Applied to me to some degree, or some of the time

2 Applied to me to a considerable degree, or a good part of time

3 Applied to me very much, or most of the time

(1) I found it hard to wind down*

0123

(2) I was aware of dryness of my mouth*

0123

(3) I couldn't seem to experience any positive feeling at all*

0123

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

0123

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

0123

(6) I tended to over-react to situations*

0123

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

0123

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

0123

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

0123

(10) I felt that I had nothing to look forward to*

0123

(11) I found myself getting agitated*

0123

(12) I found it difficult to relax*

0123

(13) I felt down-hearted and blue*

0123

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

0123

(15) I felt I was close to panic*

0123

(16) I was unable to become enthusiastic about anything*

0123

(17) I felt I wasn't worth much as a person*

0123

(18) I felt that I was rather touchy*

0123

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

0123

(20) I felt scared without any good reason*

0123

(21) I felt that life was meaningless*

0123

Depression

Anxiety

Stress

Would you like to receive a phone call to discuss your results with a therapist?

Yes, pleaseNo, thank you

Depression, Anxiety, Stress, Scale (DASS - 21)