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Date of completion
DRAM (Distress and Risk Assessment Method)        
Clinician's name (or ref) Patient's name (or ref)

The modified ZUNG Depression Index and the Modified Somatic Perception Questionnaire make up
the DRAM (Distress and Risk Assessment Method)

Modified Somatic Perception Questionnaire
Please describe how you have felt during the PAST WEEK by marking the appropriate box. Please answer all questions. Do not think too long before answering.
  Not at all A little, slightly A great deal, quite a bit Extremely, could not have been worse
1. Heart rate increase
2. Feeling hot all over
3. Sweating all over
4. Sweating in a particular part of the body
5. Pulse in neck
6. Pounding in head
7. Dizziness
8. Blurring of vision
9. Feeling faint
10. Everything appearing unreal
11. Nausea
12. Butterflies in stomach
13. Pain or ache in stomach
14. Stomach churning
15. Desire to pass water
16. Mouth becoming dry
17. Difficulty swallowing
18. Muscles in neck aching
19. Legs feeling weak
20. Muscles twitching or jumping
21. Tense feeling across forehead
22. Tense feeling in jaw muscles
 
  Modified Somatic Perception Total:
 

Modified Zung Depression Index

    
Please indicate for each of these questions which answer best describes how you have been feeling
  Rarely or none of the time
(less than 1 day per week)		 Some or little of the time
(1-2 days per week)		 A moderate amount of
time (3-4days per week)		 Most of the time
(5-7 days per week)
1. I feel downhearted and sad
2. Morning is when I feel best
3. I have crying spells or feel like it
4. I have trouble getting to sleep at night
5. I feel that nobody cares
6. I eat as much as I used to
7. I still enjoy sex
8. I notice I am losing weight
9. I have trouble with constipation
10. My heart beats faster than usual
11. I get tired for no reason
12. My mind is as clear as it used to be
13. I tend to wake up too early
14. I find it easy to do the things I used to
15. I am restless and can’t keep still
16. I feel hopeful about the future
17. I am more irritable than usual
18. I find it easy to make a decision
19. I feel quite guilty
20. I feel that I am useful and needed
21. My life is pretty full
22. I feel that others would be better off I were dead
23. I am still able to enjoy the things I used to
         
    Modified ZUNG Depression Index Total
         

DRAM (Distress and Risk Assessment Method) TOTAL:
   
Reference: Main CJ, Wood PL, Hollis S, Spanswick CC, Waddell G.The Distress and Risk Assessment Method. A simple patient classification to identify distress and evaluate the risk of poor outcome. Spine (Phila Pa 1976). 1992 Jan;17(1):42-52. This form has been modified from the ©2006 Kurer/Gooding/Dazines version.