Questionnaire (ACQ)

Hello! Please click the button below to complete a short questionnaire. Doing this regularly is one way we can track how therapy is going. Your responses will be emailed directly to Dr Forzisi.

This questionnaire has two parts. Below are some thoughts or ideas that may go through your mind when you are nervous or frightened. Indicate how often each thought occurs when you are nervous; rate each thought from 1-5 using the scale below.
1. Thought never occurs 2. Thought rarely occurs 3. Thought occurs during half of the times when I am nervous 4. Thought usually occurs 5. Thought always occurs when Iam nervous
1a. I am going to throw up
1. Thought never occurs 2. Thought rarely occurs 3. Thought occurs during half of the times when I am nervous 4. Thought usually occurs 5. Thought always occurs when I am nervous
2a. I am going to pass out
1. Thought never occurs 2. Thought rarely occurs 3. Thought occurs during half of the times when I am nervous 4. Thought usually occurs 5. Thought always occurs when I am nervous
3a. I must have a brain tumour
1. Thought never occurs 2. Thought rarely occurs 3. Thought occurs during half of the times when I am nervous 4. Thought usually occurs 5. Thought always occurs when I am nervous
4a. I will have a heart attack
1. Thought never occurs 2. Thought rarely occurs 3. Thought occurs during half of the times when I am nervous 4. Thought usually occurs 5. Thought always occurs when I am nervous
5a. I will choke to death
1. Thought never occurs 2. Thought rarely occurs 3. Thought occurs during half of the times when I am nervous 4. Thought usually occurs 5. Thought always occurs when I am nervous
6a. I am going to act foolish
1. Thought never occurs 2. Thought rarely occurs 3. Thought occurs during half of the times when I am nervous 4. Thought usually occurs 5. Thought always occurs when I am nervous
7a. I am going blind
1. Thought never occurs 2. Thought rarely occurs 3. Thought occurs during half of the times when I am nervous 4. Thought usually occurs 5. Thought always occurs when I am nervous
8a. I will not be able to control myself
1. Thought never occurs 2. Thought rarely occurs 3. Thought occurs during half of the times when I am nervous 4. Thought usually occurs 5. Thought always occurs when I am nervous
9a. I will lose control of my bladder or bowels
1. Thought never occurs 2. Thought rarely occurs 3. Thought occurs during half of the times when I am nervous 4. Thought usually occurs 5. Thought always occurs when I am nervous
10a. I will hurt someone
1. Thought never occurs 2. Thought rarely occurs 3. Thought occurs during half of the times when I am nervous 4. Thought usually occurs 5. Thought always occurs when I am nervous
11a. I am going to have a stroke
1. Thought never occurs 2. Thought rarely occurs 3. Thought occurs during half of the times when I am nervous 4. Thought usually occurs 5. Thought always occurs when I am nervous
12a. I am going to go crazy
1. Thought never occurs 2. Thought rarely occurs 3. Thought occurs during half of the times when I am nervous 4. Thought usually occurs 5. Thought always occurs when I am nervous
13a. I am going to scream
1. Thought never occurs 2. Thought rarely occurs 3. Thought occurs during half of the times when I am nervous 4. Thought usually occurs 5. Thought always occurs when I am nervous
14a. I am going to babble or talk funny
1. Thought never occurs 2. Thought rarely occurs 3. Thought occurs during half of the times when I am nervous 4. Thought usually occurs 5. Thought always occurs when I am nervous
15a. I will be paralysed with fear
1. Thought never occurs 2. Thought rarely occurs 3. Thought occurs during half of the times when I am nervous 4. Thought usually occurs 5. Thought always occurs when I am nervous
16a. I am about to die
1. Thought never occurs 2. Thought rarely occurs 3. Thought occurs during half of the times when I am nervous 4. Thought usually occurs 5. Thought always occurs when I am nervous
17a. I am seriously ill
1. Thought never occurs 2. Thought rarely occurs 3. Thought occurs during half of the times when I am nervous 4. Thought usually occurs 5. Thought always occurs when I am nervous
18a. I am going to suffocate
1. Thought never occurs 2. Thought rarely occurs 3. Thought occurs during half of the times when I am nervous 4. Thought usually occurs 5. Thought always occurs when I am nervous
When you have the symptoms of panic, how much would you believe each of these thoughts to be true. Now rate each thought by choosing a number from the scale below.
0 = I do not believe the thoughts at all 10 20 30 40 50 60 70 80 90 100 = I am completed convinced the thought is true
1b. I am going to throw up
0 = I do not believe the thoughts at all 100 = I am completed convinced the thought is true
2b. I am going to pass out
0 = I do not believe the thoughts at all 100 = I am completed convinced the thought is true
3b. I must have a brain tumour
0 = I do not believe the thoughts at all 100 = I am completed convinced the thought is true
4b. I will have a heart attack
0 = I do not believe the thoughts at all 100 = I am completed convinced the thought is true
5b. I will choke to death
0 = I do not believe the thoughts at all 100 = I am completed convinced the thought is true
6b. I am going to act foolish
0 = I do not believe the thoughts at all 100 = I am completed convinced the thought is true
7b. I am going blind
0 = I do not believe the thoughts at all 100 = I am completed convinced the thought is true
8b. I will not be able to control myself
0 = I do not believe the thoughts at all 100 = I am completed convinced the thought is true
9b. I will lose control of my bladder or bowels
0 = I do not believe the thoughts at all 100 = I am completed convinced the thought is true
10b. I will hurt someone
0 = I do not believe the thoughts at all 100 = I am completed convinced the thought is true
11b. I am going to have a stroke
0 = I do not believe the thoughts at all 100 = I am completed convinced the thought is true
12b. I am going to go crazy
0 = I do not believe the thoughts at all 100 = I am completed convinced the thought is true
13b. I am going to scream
0 = I do not believe the thoughts at all 100 = I am completed convinced the thought is true
14b. I am going to babble or talk funny
0 = I do not believe the thoughts at all 100 = I am completed convinced the thought is true
15b. I will be paralysed with fear
0 = I do not believe the thoughts at all 100 = I am completed convinced the thought is true
16b. I am about to die
0 = I do not believe the thoughts at all 100 = I am completed convinced the thought is true
17b. I am seriously ill
0 = I do not believe the thoughts at all 100 = I am completed convinced the thought is true
18b. I am going to suffocate
0 = I do not believe the thoughts at all 100 = I am completed convinced the thought is true
Finally, please rate the item below in the way you have done for the individual thoughts above; remember that the harm might include one or more of the thoughts listed above.
19a. In a panic attack, I will suffer serious physical or mental harm
1. Thought never occurs 2. Thought rarely occurs 3. Thought occurs during half of the times when I am nervous 4. Thought usually occurs 5. Thought always occurs when Iam nervous
19b. In a panic attack, I will suffer serious physical or mental harm
0 = I do not believe the thoughts at all 10 20 30 40 50 60 70 80 90 100 = I am completed convinced the thought is true