Panic Attack Survey.Please answer all items. Your answers will be e-mailed to Karin Kramer and kept confidential. Your ID Number (as assigned by Karin) I have sudden attacks of terror or panic that come from out of the blue. Not at all true Slightly true Moderately true Very true Completely true During the panic attacks I feel like I'm about to die, faint, go crazy, or lose control. Not at all true Slightly true Moderately true Very true Completely true During the panic attacks, I have intense physical symptoms such as dizziness, tingling, racing heart, tight muscles, or feeling short of breath. Not at all true Slightly true Moderately true Very true Completely true The panic attacks become absolutely terrifying within ten minutes or less. Not at all true Slightly true Moderately true Very true Completely true The panic attacks are upsetting or cause problems in my life. Not at all true Slightly true Moderately true Very true Completely true When I have a panic attack, I feel like I'm about to faint, pass out, or have a stroke. Not at all Slightly Moderately Very Extremely When I have a panic attack, I feel like I'm about to have a heart attack or die. Not at all Slightly Moderately Very Extremely When I have a panic attack, I feel like I'm about to smother or suffocate. Not at all Slightly Moderately Very Extremely When I have a panic attack, I feel like I'm about to crack up, go crazy, or lose my mind. Not at all Slightly Moderately Very Extremely When I have a panic attack, I feel like I'm about to lose control. Not at all Slightly Moderately Very Extremely How many panic attacks have you had in the past month? None One Several One per week Several per week One per day Several per day Thank you!
