1. Repeated or unexpected “attacks” during which you suddenly are overcome by fear or discomfort for no apparent reason Yes     No

If yes, during an “attack” did you experience any of these symptoms:

1. Pounding Heart Yes     No
2. Sweating Yes     No
3. Trembling or Shaking Yes     No

If yes to the first question, during an “attack” did you experience any of these symptoms (cont.)

4. Shortness of Breath Yes     No
5. Choking Yes     No
6. Chest Pain Yes     No
7. Nausea or Abdominal Discomfort Yes     No
8. “Jelly” Legs Yes     No

If yes to the very first question, during an “attack” did you experience any of these symptoms (cont.)

9. Dizziness Yes     No
10. Fear of Losing Control or “Going Crazy” Yes     No
11. Fear of Dying Yes     No
12. Numbness or Tingling Sensations Yes     No
13. Chills or Hot Flashes Yes     No

As a result of these attacks, have you:

1. 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
2. Felt unable to travel without a companion? Yes     No

For at least one month following an attack have you:

1. Felt persistent concern about having another one? Yes     No
2. Worried about having a heart attack or “Going Crazy”? Yes     No
3. Changed your behavior to accommodate the attack? Yes     No

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.

1. Have you experienced changes in sleeping or eating habits? Yes     No

More days than not, do you feel:

1. Sad or depressed? Yes     No
2. Disinterested in life? Yes     No
3. Worthless or guilty? Yes     No

During the last year, has the use of alcohol or drugs:

1. Resulted in your failure to fulfill responsibilities with work, school or family? Yes     No
2. Placed you in a dangerous situation, such as driving a car under the influence?Yes     No
3. Gotten you arrested? Yes     No
4. Continued despite causing problems for you or your loved ones? Yes     No