Psychology Paperwork

Under the Workers Compensation system, allied health professionals need to show bench marking for patients progress through an Allied Health Treatment Request. You will be asked to complete this questionnaire at the beginning of your sessions, and after 8 sessions with your Psychologist.

Please allow 20 minutes to complete this questionnaire below in its entirety.

If you have any questions, please phone our rooms on (02) 4923 8999.

DASS21

Please read each statement and select 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.

The rating scale is as follows:

Rating0123
MeaningDid 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 hard to wind down(Required)
I was aware of dryness of my mouth(Required)
I couldn't seem to experience any positive feeling at all(Required)
I experienced breathing difficulty (eg. excessively rapid breathing, breathlessness in the absence of physical exertion)(Required)
I found it difficult to work up the initiative to do things(Required)
I tended to over-react to situations(Required)
I experienced trembling (eg. in the hands)(Required)
I felt that I was using a lot of nervous energy(Required)
I was worried about situations in which I might panic and make a fool of myself(Required)
I felt that I had nothing to look forward to(Required)
I found myself getting agitated(Required)
I found it difficult to relax(Required)
I felt down-hearted and blue(Required)
I was intolerant of anything that kept me from getting on with what I was doing(Required)
I felt I was close to panic(Required)
I was unable to become enthusiastic about anything(Required)
I felt I wasn’t worth much as a person(Required)
I felt that I was rather touchy(Required)
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)(Required)
I felt scared without any good reason(Required)
I felt that life was meaningless(Required)
This field is hidden when viewing the form
This field is hidden when viewing the form
This field is hidden when viewing the form

Kessler Psychological Distress Scale (K10)

1. In the past 4 weeks, about how often did you feel tired out for no good reason?(Required)
2. In the past 4 weeks, about how often did you feel nervous?(Required)
3. In the past 4 weeks, about how often did you feel so nervous that nothing could calm you down?(Required)
4. In the past 4 weeks, about how often did you feel hopeless?(Required)
5. In the past 4 weeks, about how often did you feel restless or fidgety?(Required)
6. In the past 4 weeks, about how often did you feel so restless you could not sit still?(Required)
7. In the past 4 weeks, about how often did you feel depressed?(Required)
8. In the past 4 weeks, about how often did you feel that everything was an effort?(Required)
9. In the past 4 weeks, about how often did you feel so sad that nothing could cheer you up?(Required)
10. In the past 4 weeks, about how often did you feel worthless?(Required)
This field is hidden when viewing the form

Step 1 of 3 - Personal Details

Time
:
Name(Required)
Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains, and toothaches). Have you had pain other than these kinds of pain today?