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By taking a few minutes to fill out this form, you can teach me a lot about your healing path, and you can give me a great starting point in suggesting resources for you. Your information is kept strictly confidential.

Your first name:

Your age:

Your email address:

If you live in the U.S. or Canada, your time zone:  

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?

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?

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?  If yes, tell me a little about it:

Have you had any experience with cognitive-behavioral therapy?   If yes, tell me a little about it:

How healthy is your diet? 

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.

About how much alcohol do you drink in a typical day?

Do you smoke?

Do you do any regular exercise?  If yes, tell me a little about it:

Do you do any regular meditation, breathing or relaxation exercise?   If yes, tell me a little about it.

What are some of your sources of emotional support?
   Spouse or lover
   Friends & family
   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?

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Triumph Over Panic, Inc. is affiliated with the Agoraphobia and Panic Disorder Foundation.