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Saringan Minda Sihat (Dass-21) Form Template

Streamline mental health assessments with the Dass-21 template

Feeling overwhelmed by mental health assessments? This Dass-21 form template helps you efficiently evaluate mental well-being, making the process easier for both you and the participants. Whether you need to screen for anxiety, depression, or overall mental health, this template provides a structured approach, reduces administrative strain, and facilitates accurate data collection-all while being compliant with accessibility standards like WCAG. Dive into the template and take the first step toward clearer insights.

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Full name
Age group
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Email (optional)
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
I understand this is a self-assessment and not a diagnosis.
Yes
No
I am 18 years or older.
Yes
No
I consent to proceed with this screening.
Yes
No
Over the past week, I found it hard to wind down.
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
Over the past week, I was aware of dryness of my mouth.
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
Over the past week, I could not seem to experience any positive feeling at all.
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
Over the past week, I experienced breathing difficulty (e.g., excessively rapid breathing, breathlessness in the absence of physical exertion).
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
Over the past week, I found it difficult to work up the initiative to do things.
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
Over the past week, I tended to over-react to situations.
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
Over the past week, I experienced trembling (e.g., in the hands).
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
Over the past week, I felt that I was using a lot of nervous energy.
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
Over the past week, I was worried about situations in which I might panic and make a fool of myself.
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
Over the past week, 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
Over the past week, I found myself getting agitated.
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
Over the past week, I found it difficult to relax.
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
Over the past week, I felt downhearted and blue.
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
Over the past week, I was intolerant of anything that kept me from getting on with what I was doing.
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
Over the past week, I felt I was close to panic.
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
Over the past week, I was unable to become enthusiastic about anything.
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
Over the past week, I felt I was not worth much as a person.
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
Over the past week, I felt that I was rather touchy.
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
Over the past week, I was aware of the action of my heart in the absence of physical exertion (e.g., sense of heart rate increase, heart missing a beat).
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
Over the past week, I felt scared without any good reason.
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
Over the past week, I felt that life was meaningless.
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
Anything else you would like to share?
Date of completion
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Paper art illustration showcasing Saringan Minda Sihat Dass-21 form template for FormCreatorAI article

When to use this form

Use this 21-item screening when you need a quick, structured check of stress, anxiety, and low mood over the past week. It fits new client intake, student well-being drives, or employee check-ins, in person or online. You can triage risk, spot trends, and decide who needs brief support versus a fuller consult. For richer context about medical, social, and work factors, pair it with the Biopsychosocial assessment form. To support self-care between sessions, invite people to log wins with the Daily gratitude journal form. The result is a clear snapshot you can share with your team and use to plan next steps.

Must Ask Saringan Minda Sihat (Dass-21) Questions

  1. Over the past week, how often did you feel unable to relax or on edge?

    This gauges stress arousal and tension, which often drive sleep and focus problems. Frequency helps you prioritize who may need immediate coping strategies or a brief intervention.

  2. Over the past week, how often did you lose interest or pleasure in activities you usually enjoy?

    Anhedonia is a core sign of low mood and affects daily functioning. If responses suggest concern, follow up with the PHQ-9 & GAD-7 form to assess depression and anxiety severity.

  3. How often did worrying thoughts make it hard to concentrate on tasks?

    This links symptoms to real-world impact, which guides your care plan and workplace or school supports. It also helps you set measurable goals for follow-up.

  4. Did you notice physical signs of anxiety this week, such as a racing heart, sweaty palms, or short breath?

    Somatic cues can reveal high anxiety even when people downplay feelings. Tracking these signs supports safety planning and targeted techniques like breathing or grounding.

  5. How often did you feel overwhelmed by everyday demands or pressured by time?

    Perceived overload points to stress that may respond to practical steps such as workload changes or skills coaching. It helps you tailor referrals and short-term supports.

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