DASS21

Your full name:

Today's date:

Month	Day	Year

Briefly describe the reason you are seeking services from Swinton Counseling.

Have you previously been diagnosed with a mental health disorder?

No

Yes

If you answered "yes" to the previous question, please describe:

Medical history (please list any current or past medical issues and treatments):

Medications (including dosages) you are currently taking (prescribed and over-the-counter):

Primary care physician information (please include address, phone, and fax if available):

Would you like Swinton Counseling to collaborate with your primary care physician?

No

Yes

Please read each statement and select which statements applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

	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 the time	3: Applied to me very much, or most of the time
I found it hard to wind down

I was aware of dryness of my mouth

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

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

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

I tended to over-react to situations

I experienced trembling (eg, in the hands)

I felt that I was using a lot of nervous energy

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

I felt that I had nothing to look forward to

	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 the time	3: Applied to me very much, or most of the time
I found myself getting agitated

I found it difficult to relax

I felt down-hearted and blue

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

I felt I was close to panic

I was unable to become enthusiastic about anything

I felt I wasn't worth much as a person

I felt that I was rather touchy

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)

I felt scared without any good reason

I felt that life was meaningless

I had thoughts that I would be better off dead, or of hurting myself