Panic Attacks Assessment Questionnaire Panic Attacks Assessment Questionnaire * Input based on your choices: Yes, No First Name Last Name Phone (###) ### #### Email * What triggers your panic attacks? * 1. Repeated or unexpected “attacks” during which you suddenly are overcome by intense fear or discomfort for no apparent reason If yes, during an attack did you experience any of these symptoms? Yes No 2. Pounding heart Yes No 3. Sweating Yes No 4. Trembling or shaking Yes No 5. Shortness of breath Yes No 6. Choking Yes No 7. Chest pain Yes No 8. Nausea or abdominal discomfort Yes No 9. "Jelly" legs Yes No 10. Dizziness Yes No 11. Fear of losing control or "going crazy" Yes No 12. Fear of dying Yes No 13. Numbness or tingling sensations Yes No 14. Chills or hot flushes Yes No 15. As a result of these attacks, have you experienced a fear of places or situations where getting help or escape might be difficult, such as in a crowd or on a bridge? Yes No 16. As a result of these attacks, have you felt unable to travel without a companion? Yes No 17. For at least one month following an attack, have you felt persistent concern about having another one? Yes No 18. For at least one month following an attack, have you worried about having a heart attack or “going crazy”? Yes No 19. For at least one month following an attack, have you changed your behavior to accommodate the attack? Yes No 20. Having more than one illness at the same time can make it difficult to diagnose and treat the different conditions. Depression and substance abuse are among the conditions that occasionally complicate panic disorder. Have you experienced changes in sleeping or eating habits? Yes No More days than not, do you feel sad or depressed? Yes No More days than not, do you feel disinterested in life? Yes No More days than not, do you feel worthless or guilty? Yes No During the last year, has the use of alcohol or drugs resulted in your failure to fulfill responsibilities with work, school, or family? Yes No During the last year, has the use of alcohol or drugs placed you in a dangerous situation, such as driving a car under the influence? Yes No During the last year, has the use of alcohol or drugs gotten you arrested? Yes No During the last year, has the use of alcohol or drugs continued despite causing problems for you or your loved ones? Yes No Thank you!
