Wellspring Pain Clinic Sydney | Chronic Pain Management & Treatment

First Name *

Surname *

Date of birth *

Address *

Postcode *

Email Address *

Phone - Mobile *

Phone - Home

Phone - Work

Please read each statement and select 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 (Never)
1 - Applied to me to some degree, or some of the time (Sometimes)
2 - Applied to me to a considerable degree, or a good part of time (Often)
3 - Applied to me very much, or most of the time (Almost Always)

Scores

DEPRESSION SCORE

(D) Scoring Guide

Normal

ANXIETY SCORE

(A) Scoring Guide

Normal

STRESS SCORE

(S) Scoring Guide

Normal

Online Patient Registration Form

DASS (Depression Anxiety Stress Scale) 21

Scores

DEPRESSION SCORE

ANXIETY SCORE

STRESS SCORE