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The following questionnaire provides a list of symptoms you may currently experience.
Please answer as honestly as you can!
Which of the following symptoms are Which of the following situations do you try
troublesome for you? to avoid? (Check and circle the ones that apply):
1. Category P: 3. Category PAb:
Pounding or racing heart Crowded public places: supermarkets,
Chest pain or discomfort theatres, malls, sport events, etc.
Shortness of breath or smothering sensations Enclosed and confined places: tunnels,
Trembling or shaking bridges, small rooms, elevators, airplanes,
Feeling of choking subways, buses, getting a haircut, long lines,
Sweating other: __________________
Dizziness, unsteady feeling, Driving: especially on highways and
lightheadedness, or faintness bridges, bad traffic, and over long distances
Nausea or abdominal distress Being away from home
Feeling you or your surroundings are strange Being alone
or unreal
Numbness or tingling in face, hands, or legs 4. Category SP:
Hot flashes or chills Situations (heights, closed spaces, dentists,
Fear of dying (e.g., fear of having a heart elevators, airplanes/flying)
attack) Animals (snakes, rats, spiders, dogs, other:
Fear of going crazy _______________)
Fear of doing something uncontrolled Natural environment (heights, storms,
Panicky feelings are: lightning, water)
Unexpected Illness or bodily harm (disease, injuries)
Occurring when you are confronted by Sight of blood or needles makes you queasy
something frightening Other (choking, eating certain foods,
vomiting)
2. Category PAa: Being exposed to any of these makes you
Sitting near exits when at the movies or in a feel anxious or panicky
restaurant You know that your fear of these situations
Checking where the closest exit is when is excessive or unreasonable
visiting a shopping mall
Carrying medication, money, cell phone, Which of the following applies to you?
pager, water, or other safety items
Avoiding activities (like exercise, sex, or 5. Category G:
thriller movies) that might trigger physical Cannot stop worrying even if it doesn’t
arousal seem to solve anything or is unproductive
Drinking alcohol to combat feelings of panic Feeling restless
Avoiding caffeine, alcohol, or other Feeling on edge or keyed up
substances Excessive muscle tensions
Frequently checking blood pressure Being easily fatigued
Distracting yourself from panicky feelings Difficulty concentrating
(e.g., by watching TV or reading) Mind going blank
Insisting on being accompanied when Feeling irritable
leaving the house Difficulties sleeping
Always needing to know the whereabouts of Waking up and instantly starting to worry
your spouse, partner, or other “safe” person Difficulty controlling worries or symptoms
Symptoms have lasted for more days than
not for more than 6 months