Severity Measure for Panic Disorder

Severity Measure for Panic Disorder—Adult
Name

First NameMiddle NameLast Name
Medical Record #
Date

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2 digit month, 2 digit day, 4 digit yearDate
Instructions: The following questions ask about thoughts, feelings, and behaviors about panic attacks. A panic attack is an episode of intense fear that sometimes comes out of the blue (for no apparent reason). The symptoms of a panic attack include: a racing heart, shortness of breath, dizziness, sweating, and fear of losing control or dying.

During the PAST 7 DAYS, I have...

Rows	Never	Occasionally	Half of the time	Most of the time	All of the time
felt moments of sudden terror, fear or fright, sometimes out of the blue (i.e., a panic attack)
felt anxious, worried, or nervous about having more panic attacks
had thoughts of losing control, dying, going crazy, or other bad things happening because of panic attacks
felt a racing heart, sweaty, trouble breathing, faint, or shaky
felt tense muscles, felt on edge or restless, or had trouble relaxing or trouble sleeping
avoided, or did not approach or enter, situations in which panic attacks might occur
left situations early, or participated only minimally, because of panic attacks
spent a lot of time preparing for, or procrastinating about (putting off), situations in which panic attacks might occur
distracted myself to avoid thinking about panic attacks
needed help to cope with panic attacks (e.g., alcohol or medication, superstitious objects, other people)

Severity Measure for Panic Disorder—Adult