Your first name:

Your age:

Your email address:

If you live in the U.S. or Canada, your time zone:  Pacific Mountain Central Eastern  

If you live in another country, where do you live? 

On a typical day, what is your average level of anxiety, with "0" being completely calm and peaceful and "10" being a panic attack?

In the last week, about how many panic attacks have you experienced?

In the last month, about how many panic attacks?

Do you believe a panic attack can be dangerous? Yes No Not sure

Which of the following are "triggers" for panic for you:
   Traveling far from home by yourself
   Going to a crowded restaurant or theater
   Taking an elevator up 10 stories
   Going on an airplane trip

Which of the following are among your top fears:
   Being embarrassed in a social situation
   Being watched closely when doing something
   Being the center of attention

Do you often avoid social events or social situations? Yes No

Tell me a little about how your activities are restricted by your condition:

What do you think is your correct diagnosis?

About how long ago did this condition start?

What other psychological or physical conditions do you have?

What medications are you currently taking?

Have you tried medications in the past that you are not taking now?  If yes, tell me a little about your experience.

Are you currently in therapy?  Yes No If yes, tell me a little about it:

Have you had any experience with cognitive-behavioral therapy?  Yes No   If yes, tell me a little about it:

How healthy is your diet?  Very healthy Better than average Average diet Worse than average

About how much caffeine do you drink in a typical day? One regular cup of coffee is equivalent to two cups of tea or two caffeinated soft drinks.
None Equivalent of one cup of tea or one soft drink Equivalent of one cup of coffee Two cups of coffee 3 to 4 cups of coffee More than 4 cups of coffee

About how much alcohol do you drink in a typical day?
None One drink (equal to one beer or one glass of wine) Two drinks 3-4 drinks More than 4 drinks

Do you do any regular exercise?  Yes No If yes, tell me a little about it:

Do you do any regular meditation, breathing or relaxation exercise?  Yes No   If yes, tell me a little about it.

What are some of your sources of emotional support?
   Spouse or lover
   Friends & family
   Therapist
   Church or synagogue
   Support group
   Internet chatrooms and message boards
    Is there a particular chatroom or message board that has been helpful?
   

What "big life issues," if any, do you think may be relevant?  Examples of "big life issues" are: traumatic events, loss or illness of a loved one, separation or divorce, job change or moving to a new city.

Is there anything you'd like to add?