Depression Anxiety Stress Scales (DASS-21)

Please complete this form before our first meeting.

Client Information

First name

Last name

Email address

Phone number

Please read each statement and choose a selection 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.

I found it hard to wind down

Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time

I was aware of dryness of my mouth

Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time

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

Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time

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

Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time

I found it difficult to work up the initiative to do things

Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time

I tended to over-react to situations

Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time

I experienced trembling (eg, in the hands)

Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time

I felt that I was using a lot of nervous energy

Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time

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

Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time

I felt that I had nothing to look forward to

Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time

I found myself getting agitated

Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time

I found it difficult to relax

Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time

I felt down-hearted and blue

Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time

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

Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time

I felt I was close to panic

Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time

I was unable to become enthusiastic about anything

Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time

I felt I wasn't worth much as a person

Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time

I felt that I was rather touchy

Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time

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)

Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time

I felt scared without any good reason

Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time

I felt that life was meaningless

Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time

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Depression Anxiety Stress Scales (DASS-21)

Please complete this form before our first meeting.

Client Information

Please read each statement and choose a selection 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.

Please complete this form before our first meeting.

David Friedler, LMHC, MPH