DASS Survey

0 Never

1 Sometimes

2 Often

3 Always

I found it hard to wind down (S)

I found it hard to wind down (S) 0 Never

I found it hard to wind down (S) 1 Sometimes

I found it hard to wind down (S) 2 Often

I found it hard to wind down (S) 3 Always

I was aware of dryness of my mouth (A)

I was aware of dryness of my mouth (A) 0 Never

I was aware of dryness of my mouth (A) 1 Sometimes

I was aware of dryness of my mouth (A) 2 Often

I was aware of dryness of my mouth (A) 3 Always

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

I couldn't seem to experience any positive feeling at all (D) 0 Never

I couldn't seem to experience any positive feeling at all (D) 1 Sometimes

I couldn't seem to experience any positive feeling at all (D) 2 Often

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

I experience breathing difficulty (eg excessive rapid breathing, breathlessness in the absence of physical exertion) (A)

I experience breathing difficulty (eg excessive rapid breathing, breathlessness in the absence of physical exertion) (A) 0 Never

I experience breathing difficulty (eg excessive rapid breathing, breathlessness in the absence of physical exertion) (A) 1 Sometimes

I experience breathing difficulty (eg excessive rapid breathing, breathlessness in the absence of physical exertion) (A) 2 Often

I experience breathing difficulty (eg excessive rapid breathing, breathlessness in the absence of physical exertion) (A) 3 Always

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

I found it difficult to work up the initiative to do things (D) 0 Never

I found it difficult to work up the initiative to do things (D) 1 Sometimes

I found it difficult to work up the initiative to do things (D) 2 Often

I found it difficult to work up the initiative to do things (D) 3 Always

I tended to over react to situations (S)

I tended to over react to situations (S) 0 Never

I tended to over react to situations (S) 1 Sometimes

I tended to over react to situations (S) 2 Often

I tended to over react to situations (S) 3 Always

I experience trembling (eg in the hands) (A)

I experience trembling (eg in the hands) (A) 0 Never

I experience trembling (eg in the hands) (A) 1 Sometimes

I experience trembling (eg in the hands) (A) 2 Often

I experience trembling (eg in the hands) (A) 3 Always

I felt that i was using a lot of nervous energy (S)

I felt that i was using a lot of nervous energy (S) 0 Never

I felt that i was using a lot of nervous energy (S) 1 Sometimes

I felt that i was using a lot of nervous energy (S) 2 Often

I felt that i was using a lot of nervous energy (S) 3 Always

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

I was worried about situations in which I might panic and make a fool of myself (A) 0 Never

I was worried about situations in which I might panic and make a fool of myself (A) 1 Sometimes

I was worried about situations in which I might panic and make a fool of myself (A) 2 Often

I was worried about situations in which I might panic and make a fool of myself (A) 3 Always

I felt that I had nothing to look forward to (D)

I felt that I had nothing to look forward to (D) 0 Never

I felt that I had nothing to look forward to (D) 1 Sometimes

I felt that I had nothing to look forward to (D) 2 Often

I felt that I had nothing to look forward to (D) 3 Always

I found myself getting agitated (S)

I found myself getting agitated (S) 0 Never

I found myself getting agitated (S) 1 Sometimes

I found myself getting agitated (S) 2 Often

I found myself getting agitated (S) 3 Always

I found it difficult to relax (S)

I found it difficult to relax (S) 0 Never

I found it difficult to relax (S) 1 Sometimes

I found it difficult to relax (S) 2 Often

I found it difficult to relax (S) 3 Always

I felt downhearted and blue (D)

I felt downhearted and blue (D) 0 Never

I felt downhearted and blue (D) 1 Sometimes

I felt downhearted and blue (D) 2 Often

I felt downhearted and blue (D) 3 Always

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

I was intolerant of anything that kept me from getting on with what I was doing (S) 0 Never

I was intolerant of anything that kept me from getting on with what I was doing (S) 1 Sometimes

I was intolerant of anything that kept me from getting on with what I was doing (S) 2 Often

I was intolerant of anything that kept me from getting on with what I was doing (S) 3 Always

I felt I was close to panic (A)

I felt I was close to panic (A) 0 Never

I felt I was close to panic (A) 1 Sometimes

I felt I was close to panic (A) 2 Often

I felt I was close to panic (A) 3 Always

I was unable to become enthusiastic about anything (D)

I was unable to become enthusiastic about anything (D) 0 Never

I was unable to become enthusiastic about anything (D) 1 Sometimes

I was unable to become enthusiastic about anything (D) 2 Often

I was unable to become enthusiastic about anything (D) 3 Always

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

I felt I wasn't worth much as a person (D) 0 Never

I felt I wasn't worth much as a person (D) 1 Sometimes

I felt I wasn't worth much as a person (D) 2 Often

I felt I wasn't worth much as a person (D) 3 Always

I felt that I was rather touchy (S)

I felt that I was rather touchy (S) 0 Never

I felt that I was rather touchy (S) 1 Sometimes

I felt that I was rather touchy (S) 2 Often

I felt that I was rather touchy (S) 3 Always

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) (A)

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) (A) 0 Never

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) (A) 1 Sometimes

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) (A) 2 Often

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) (A) 3 Always

I felt scared without any good reason (A)

I felt scared without any good reason (A) 0 Never

I felt scared without any good reason (A) 1 Sometimes

I felt scared without any good reason (A) 2 Often

I felt scared without any good reason (A) 3 Always

I felt that life was meaningless (D)

I felt that life was meaningless (D) 0 Never

I felt that life was meaningless (D) 1 Sometimes

I felt that life was meaningless (D) 2 Often

I felt that life was meaningless (D) 3 Always

Question Title

* 3. Interpretation of scores (for office use only)

TOTAL SCORE: add up the total scores for each category and then multiple number by 2 : S= ___, A=_, D=________

Score Range: N=normal, Md=mild, M=moderate, S=severe, ES=extremely severe

D - N 0-9, Md 10-13, M 14-20, S 21-27, ES 28+

A - N 0-7, Md 8-9, M 10-14, S 15-19, ES 20+

S - N 0-14, Md 15-19, M 19-25, S 26-33, ES 34+

This questionnaire is taken from: Osman A, Wong JL, Bagge CL, Freedenthal S, Gutierrez PM, Lozano G. The depression anxiety stress Scales—21 (DASS‐21): further examination of dimensions, scale reliability, and correlates. Journal of clinical psychology. 2012 Dec;68(12):1322-38.

DASS

DASS Scale

Question Title

* 1. Client Name: Surname, First Name

Question Title

* 2. 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.

Question Title

Question Title

* 1. Client Name: Surname, First Name

Question Title

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

Question Title

* 2. 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.