Panic Attacks Assessment Questionnaire Patient Name * *Phone Number * *Email Address * *If yes, during an attack did you experience any of these symptoms?YesNoPounding heartYesNoSweatingYesNoTrembling or shakingYesNoShortness of breathYesNoChokingYesNoChest painYesNoNausea or abdominal discomfortYesNo"Jelly" legsYesNoDizzinessYesNoFear of losing control or "going crazy"YesNoFear of dyingYesNoNumbness or tingling sensationsYesNoChills or hot flushesYesNoAs 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?YesNoAs a result of these attacks, have you felt unable to travel without a companion?YesNoFor at least one month following an attack, have you felt persistent concern about having another one?YesNoFor at least one month following an attack, have you worried about having a heart attack or “going crazy”?YesNoFor at least one month following an attack, have you changed your behavior to accommodate the attack?YesNoHave you experienced changes in sleeping or eating habits?YesNoMore days than not, do you feel sad or depressed?YesNoMore days than not, do you feel disinterested in life?YesNoMore days than not, do you feel worthless or guilty?YesNoDuring the last year, has the use of alcohol or drugs resulted in your failure to fulfill responsibilities with work, school, or family?YesNoDuring the last year, has the use of alcohol or drugs placed you in a dangerous situation, such as driving a car under the influence?YesNoDuring the last year, has the use of alcohol or drugs gotten you arrested?YesNoDuring the last year, has the use of alcohol or drugs continued despite causing problems for you or your loved ones?YesNo Submit
