Date of Completion

DRAM (Distress and Risk Assessment Method)
Clinician's name (or ref)
Patient's name (or ref)
Patient's d.o.b
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 a check mark (√) in the appropriate box. Please answer all questions. Do not think too long before answering.
1. Heart rate increase
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
2. Feeling hot all over
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
3. Sweating all over
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
4. Sweating in a particular part of the body
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
5. Pulse in neck
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
6. Pounding in head
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
7. Dizziness
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
8. Blurring of vision
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
9. Feeling faint
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
10. Everything appearing unreal
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
11. Nausea
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
12. Butterflies in stomach
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
13. Pain or ache in stomach
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
14. Stomach churning
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
15. Desire to pass water
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
16. Mouth becoming dry
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
17.Difficulty swallowing
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
18. Muscles in neck aching
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
19. Legs feeling weak
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
20. Muscles twitching or jumping
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
21. Tense feeling across forehead
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
22. Tense feeling in jaw muscles
Not at all
A little, slightly
A great deal, quite a bit
Extremely,could not have been worse
Total:

Modified Zung Depression Index

Please indicate for each of these questions which answer best describes how you have been feeling
1. I feel downhearted and sad
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)
2. Morning is when I feel best
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)
3. I have crying spells or feel like it
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)
4. I have trouble getting to sleep at night
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)
5. I feel that nobody cares
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)
6. I eat as much as I used to
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)
7. I still enjoy sex
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)
8. I notice I am losing weight
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)
9. I have trouble with constipation
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)
10. My heart beats faster than usual
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)
11. I get tired for no reason
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)
12. My mind is as clear as it used to be
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)
13. I tend to wake up too early
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)
14. I find it easy to do the things I used to
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)
15. I am restless and can't keep still
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)
16. I feel hopeful about the future
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)
17. I am more irritable than usual
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)
18. I find it easy to make a decision
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)
19. I feel quite guilty
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)
20. I feel that I am useful and needed
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)
21. My life is pretty full
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)
22. I feel that others would be better off I were dead
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)
23. I am still able to enjoy the things I used to
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)
Total:
DRAM (Distress and Risk Assessment Method):

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Physical symptoms Score is:
%
Sports/recreation/work Score is:
%
Lifestyle Score is:
%
Emotion Score is:
%
Emotion Score is:
%
Reference:

Waddell C, Newton M, Henderson I, et al. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993; 52:157-168.

Fritz JM, George S.Identifying Psychosocial Variables in Patients With Acute Work-Related Low Back Pain: The Importance of Fear-Avoidance Beliefs. Phys Ther. 2002; 82(10): 973-983.

Lethem J, Slade PD, Troup JDG, Bendey G. Outline of a fear avoidance model of exaggerated pain perceptions, Behav Res Ther. 1983;21:401-408.

Williamson E. Fear Avoidance Behavior Questionnaire. Austrailian Journal of Physiotherapy. 2006; 52: 149.

Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eck H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain. 1995;62: 36, 272.