| The following self test has been developed to assist adults in determining if they may be experiencing symptoms related to panic attacks. This is only a preliminary questionaire and should not be used to diagnose or treat any condition, disorder or disease. |
| |
| |
| 1. Have you experienced an attack brought on by intense fear or discomfort that included heart palpitations, racing heart rate, or pounding of the heart, starting suddenly and ending within a short amount of time? |
| Yes |
| No |
| |
| |
| 2. Have you experienced an attack brought on by intense fear or discomfort that included excessive sweating, starting suddenly and ending within a short amount of time? |
| Yes |
| No |
| |
| |
| 3. Have you experienced an attack brought on by intense fear or discomfort that included pain in the chest, starting suddenly and ending within a short amount of time? |
| Yes |
| No |
| |
| |
| 4. Have you experienced an attack brought on by intense fear or discomfort that included dizziness, lightheadedness, or a feeling as if you’re about to faint, starting suddenly and ending within a short amount of time? |
| Yes |
| No |
| |
| |
| 5. Have you experienced an attack brought on by intense fear or discomfort that included nausea or severe stomach upset, starting suddenly and ending within a short amount of time? |
| Yes |
| No |
| |
| |
| 6. Have you experienced an attack brought on by intense fear or discomfort that included shaking or trembling, starting suddenly and ending within a short amount of time? |
| Yes |
| No |
| |
| |
| 7. Have you experienced an attack brought on by intense fear or discomfort that included shortness of breath or feeling as if you cannot breathe, starting suddenly and ending within a short amount of time? |
| Yes |
| No |
| |
| |
| 8. Have you experienced an attack brought on by intense fear or discomfort that included chills, hot flashes, numbness or tingling sensations, starting suddenly and ending within a short amount of time? |
| Yes |
| No |
| |
| |
| 9. Have you experienced an attack brought on by intense fear or discomfort that included an overwhelming fear of death or dying, starting suddenly and ending within a short amount of time? |
| Yes |
| No |
| |
| |
| 10. If you’ve had an attack like the one above, did you find yourself preoccupied with worry that another attack would occur for at least a month afterward? |
| Yes |
| No |
| |
| |
| 11. Do you worry that having another attack will cause you to suffer a heart attack or go crazy? |
| Yes |
| No |
| |
| |
| 12. Were you using drugs, alcohol, or medication of any kind at the time of the attack? |
| Yes |
| No |
| |
| |
| 13. Since the attack, have you taken great pains to avoid any activity or place that might cause you to have another attack, even if this avoidance interferes with living your life? |
| Yes |
| No |
| |
| |
|
|
| |
| |
|
| |
