DASS Form Template

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

First NameLast Name
Date

DayMonthYearHourMinutesAM/PM Option

Dass 21

Hello and thank you very much for filling out the DASS 21 Intake Form.

This gives me a baseline of information to work from for each client.

Once you submit the form it emails me the results.

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
Should be Empty:

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