Panic Disorder Severity Assessment-Adult

Assessment 1 of 13

Form Instructions & Things to Know

How to fill this form:
  • Read each question carefully before selecting an answer.
  • Select the most accurate option based on your observations.
  • Do not skip questions; every response helps in the assessment.
Things to know:
10-15 Mins

Estimated completion time.

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Note: This is a screening and assessment tool, not clinical (medical).

First, please provide your contact information.

Information about the individual being assessed.

1. During the PAST 7 DAYS, I have felt moments of sudden terror, fear or fright, sometimes out of the blue (i.e., a panic attack)
2. During the PAST 7 DAYS, I have felt anxious, worried, or nervous about having more panic attacks
3. During the PAST 7 DAYS, I have had thoughts of losing control, dying, going crazy, or other bad things happening because of panic attacks
4. During the PAST 7 DAYS, I have felt a racing heart, sweaty, trouble breathing, faint, or shaky
5. During the PAST 7 DAYS, I have felt tense muscles, felt on edge or restless,m or had trouble relaxing or trouble sleeping
6. During the PAST 7 DAYS, I have avoided, or did not approach or enter, situations in which panic attacks might occur
7. During the PAST 7 DAYS, I have left situations early, or participated only minimally, because of panic attacks
8. During the PAST 7 DAYS, I have spent a lot of time preparing for, or procrastinating about (putting off), situations in which panic attacks might occur
9. During the PAST 7 DAYS, I have distracted myself to avoid thinking about panic attacks
10. During the PAST 7 DAYS, I have needed help to cope with panic attacks (e.g., alcohol or medication, superstitious objects, other people)