Questionnaire (Panic)

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.

A panic attack means a SUDDEN increase in anxiety during which FOUR OR MORE of the following sensations are experienced
1. Feeling short of breath 2. Palpitations or heart racing 3. Choking 4. Chest feeling uncomfortable or painful 5. Sweating 6. Dizziness, unsteady feelings or faintness 7. Feeling unreal or detached from yourself 8. Nausea or discomfort in the stomach 9. Hot or cold flushes 10. Trembling or shaking 11. Numbness or tingling feelings (pins and needles) 12. Fear of dying 13. Fear of doing something uncontrolled or going crazy during an attack
1. What was the frequency of your panic attacks during the last two weeks?
0 = No panic attacks 1 = One panic attack per fortnight 2 = One or two panic attacks per week 3 = At least three panic attacks per week but averaging less than one per day 4 = One or more panic attacks per day
2. How severe a problem are panic attacks for you at present?
0 = Not at all disturbing and/or disabling 1 2 = Slightly disturbing and/or disabling 3 4 = Definitely disturbing and/or disabling 5 6 = Markedly disturbing and/or disabling 7 8 = Very disturbing and/or disabling
3. In the past two weeks, how much have you avoided situations (or needed someone to accompany you) due to fear that you may panic/ have symptoms? Examples are: being outside home alone, travelling, being in a crowd, supermarket or department store?
0 = Never avoid 1 2 = Occasionally avoid 3 4 = Moderate avoidance 5 6 = Severe avoidance 7 8 = Always Avoid