Saringan Minda Sihat - DASS 21

Nama / Full Name *

Jantina / Gender *

Lelaki / Male         Perempuan / Female

Bangsa / Race *

Umur / Age *

Kategori / Category *

Staf Kesihatan         Orang Awam / Public

Daerah / District *

Alamat / Address *

Emel / Email *

No. Telefon / Telephone number *

Adakah anda mempunyai masalah penyakit kronik seperti Diabetes, Hipertensi, atau Masalah Sakit Jantung? *

Ya         Tidak

Adakah anda merokok?
Description : Adakah anda merokok dalam tempoh 6 bulan ini?
*

Ya         Tidak

Adakah anda terlibat dalam pengambilan dadah / alkohol? *

Ya         Tidak

Adakah anda mempunyai sejarah penyakit mental dalam pemantauan pakar psikiatri?
Description : Adakah anda mempunyai temujanji secara berkala dengan pakar psikiatri / pakar perubatan keluarga untuk masalah psikiatri atau mengambil ubatan psikotropik?
*

Ya         Tidak

Adakah anda mempunyai masalah berat badan berlebihan atau obesiti? *

Ya         Tidak

Sila baca kenyataan dan tandakan jawapan (skala markah 0,1,2,3) yang menggambarkan keadaan anda SEMINGGU yang lepas. Tidak ada jawapan yang betul atau salah. JANGAN guna terlalu banyak masa untuk mana-mana kenyataan. Skala markah adalah seperti berikut:
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:

KeteranganSkala Markah
Tidak pernah sama sekali
Did not apply to me at all
0
Jarang
Applied to me to some degree, or some of the time
1
Kerap
Applied to me to a considerable degree, or a good part of time
2
Sangat Kerap
Applied to me very much, or most of the time
3

1) Saya rasa susah untuk bertenang / I found it hard to wind down *

0 = Tidak pernah sama sekali / Did not apply to me at all
1 = Jarang / Applied to me to some degree, or some of the time
2 = Kerap / Applied to me to a considerable degree, or a good part of time
3 = Sangat Kerap / Applied to me very much, or most of the time

0           1           2           3

2) Saya sedar mulut saya rasa kering / I was aware of dryness of my mouth *

0 = Tidak pernah sama sekali / Did not apply to me at all
1 = Jarang / Applied to me to some degree, or some of the time
2 = Kerap / Applied to me to a considerable degree, or a good part of time
3 = Sangat Kerap / Applied to me very much, or most of the time

0           1           2           3

3) Saya seolah-olah tidak dapat mengalami perasaan positif sama sekali / I couldn't seem to experience any positive feeling at all *

0 = Tidak pernah sama sekali / Did not apply to me at all
1 = Jarang / Applied to me to some degree, or some of the time
2 = Kerap / Applied to me to a considerable degree, or a good part of time
3 = Sangat Kerap / Applied to me very much, or most of the time

0           1           2           3

4) Saya mengalami kesukaran bernafas (contohnya, bernafas terlalu cepat tercungap-cungap walaupun tidak melakukan aktiviti fizikal / I experienced breathing difficulty (eg, excessively rapid breathing,breathlessness in the absence of physical exertion) *

0 = Tidak pernah sama sekali / Did not apply to me at all
1 = Jarang / Applied to me to some degree, or some of the time
2 = Kerap / Applied to me to a considerable degree, or a good part of time
3 = Sangat Kerap / Applied to me very much, or most of the time

0           1           2           3

5) Saya rasa tidak bersemangat untuk memulakan sesuatu keadaan / I found it difficult to work up the initiative to do things *

0 = Tidak pernah sama sekali / Did not apply to me at all
1 = Jarang / Applied to me to some degree, or some of the time
2 = Kerap / Applied to me to a considerable degree, or a good part of time
3 = Sangat Kerap / Applied to me very much, or most of the time

0           1           2           3

6) Saya cenderung bertindak secara berlebihan kepada sesuatu keadaan / I tended to over-react to situations *

0 = Tidak pernah sama sekali / Did not apply to me at all
1 = Jarang / Applied to me to some degree, or some of the time
2 = Kerap / Applied to me to a considerable degree, or a good part of time
3 = Sangat Kerap / Applied to me very much, or most of the time

0           1           2           3

7) Saya pernah menggeletar (contohnya tangan) / I experienced trembling (eg, in the hands) *

0 = Tidak pernah sama sekali / Did not apply to me at all
1 = Jarang / Applied to me to some degree, or some of the time
2 = Kerap / Applied to me to a considerable degree, or a good part of time
3 = Sangat Kerap / Applied to me very much, or most of the time

0           1           2           3

8) Saya rasa saya terlalu gelisah / I felt that I was using a lot of nervous energy *

0 = Tidak pernah sama sekali / Did not apply to me at all
1 = Jarang / Applied to me to some degree, or some of the time
2 = Kerap / Applied to me to a considerable degree, or a good part of time
3 = Sangat Kerap / Applied to me very much, or most of the time

0           1           2           3

9) Saya risau akan berlaku keadaan di mana saya panik dan berkelakuan bodoh / I was worried about situations in which I might panic and make a fool of myself *

0 = Tidak pernah sama sekali / Did not apply to me at all
1 = Jarang / Applied to me to some degree, or some of the time
2 = Kerap / Applied to me to a considerable degree, or a good part of time
3 = Sangat Kerap / Applied to me very much, or most of the time

0           1           2           3

10) Saya rasa tidak ada yang saya harapkan (putus harapan) / I felt that I had nothing to look forward to *

0 = Tidak pernah sama sekali / Did not apply to me at all
1 = Jarang / Applied to me to some degree, or some of the time
2 = Kerap / Applied to me to a considerable degree, or a good part of time
3 = Sangat Kerap / Applied to me very much, or most of the time

0           1           2           3

11) Saya dapati saya mudah resah / I found myself getting agitated *

0 = Tidak pernah sama sekali / Did not apply to me at all
1 = Jarang / Applied to me to some degree, or some of the time
2 = Kerap / Applied to me to a considerable degree, or a good part of time
3 = Sangat Kerap / Applied to me very much, or most of the time

0           1           2           3

12) Saya merasa sukar untuk relaks / I found it difficult to relax *

0 = Tidak pernah sama sekali / Did not apply to me at all
1 = Jarang / Applied to me to some degree, or some of the time
2 = Kerap / Applied to me to a considerable degree, or a good part of time
3 = Sangat Kerap / Applied to me very much, or most of the time

0           1           2           3

13) Saya rasa muram dan sedih / I felt down-hearted and blue *

0 = Tidak pernah sama sekali / Did not apply to me at all
1 = Jarang / Applied to me to some degree, or some of the time
2 = Kerap / Applied to me to a considerable degree, or a good part of time
3 = Sangat Kerap / Applied to me very much, or most of the time

0           1           2           3

14) Saya tidak boleh terima apa jua yang menghalangi saya daripada meneruskan apa yang saya sedang lakukan / I was intolerant of anything that kept me from getting on with what I was doing *

0 = Tidak pernah sama sekali / Did not apply to me at all
1 = Jarang / Applied to me to some degree, or some of the time
2 = Kerap / Applied to me to a considerable degree, or a good part of time
3 = Sangat Kerap / Applied to me very much, or most of the time

0           1           2           3

15) Saya rasa hampir panik / I felt I was close to panic *

0 = Tidak pernah sama sekali / Did not apply to me at all
1 = Jarang / Applied to me to some degree, or some of the time
2 = Kerap / Applied to me to a considerable degree, or a good part of time
3 = Sangat Kerap / Applied to me very much, or most of the time

0           1           2           3

16) Saya tidak bersemangat langsung / I was unable to become enthusiastic about anything *

0 = Tidak pernah sama sekali / Did not apply to me at all
1 = Jarang / Applied to me to some degree, or some of the time
2 = Kerap / Applied to me to a considerable degree, or a good part of time
3 = Sangat Kerap / Applied to me very much, or most of the time

0           1           2           3

17) Saya rasa diri saya tidak berharga / I felt I wasn't worth much as a person *

0 = Tidak pernah sama sekali / Did not apply to me at all
1 = Jarang / Applied to me to some degree, or some of the time
2 = Kerap / Applied to me to a considerable degree, or a good part of time
3 = Sangat Kerap / Applied to me very much, or most of the time

0           1           2           3

18) Saya mudah tersinggung / I felt that I was rather touchy *

0 = Tidak pernah sama sekali / Did not apply to me at all
1 = Jarang / Applied to me to some degree, or some of the time
2 = Kerap / Applied to me to a considerable degree, or a good part of time
3 = Sangat Kerap / Applied to me very much, or most of the time

0           1           2           3

19) Walaupun saya tidak melakukan aktiviti fizikal, saya sedar akan debaran jantung saya (contoh: degupan jantung lebih cepat) / 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) *

0 = Tidak pernah sama sekali / Did not apply to me at all
1 = Jarang / Applied to me to some degree, or some of the time
2 = Kerap / Applied to me to a considerable degree, or a good part of time
3 = Sangat Kerap / Applied to me very much, or most of the time

0           1           2           3

20) Saya rasa takut tanpa sebab / I felt scared without any good reason *

0 = Tidak pernah sama sekali / Did not apply to me at all
1 = Jarang / Applied to me to some degree, or some of the time
2 = Kerap / Applied to me to a considerable degree, or a good part of time
3 = Sangat Kerap / Applied to me very much, or most of the time

0           1           2           3

21) Saya rasa hidup ini tidak beerti lagi / I felt that life was meaningless *

0 = Tidak pernah sama sekali / Did not apply to me at all
1 = Jarang / Applied to me to some degree, or some of the time
2 = Kerap / Applied to me to a considerable degree, or a good part of time
3 = Sangat Kerap / Applied to me very much, or most of the time

0           1           2           3