1. Frequency.
No panic attack in the past week
1 panic attack in the past week
2 or 3 panic attacks in the past week
4-6 panic attacks in the past week
2. Severity.
Attacks were usually very mild
Attacks were usually moderate
Attacks were usually severe
Attacks were usually extremely severe
3. Average duration of panic attacks.
4. Avoidance behaviour.
No avoidance (or no agoraphobia)
Infrequent avoidance of feared situations
Occasional avoidance of feared situations
Frequent avoidance of feared situations
Very frequent avoidance of feared situations
5. Number of feared situations: How many situations are avoided or induce panic attacks or discomfort?
Occurred in very many different situations
6. Importance of avoided situations: How important are the avoided situations?
Unimportant (or no agoraphobia)
7. Frequency.
No fear of having a panic attack
Infrequent fear of having a panic attack
Sometimes fear of having a panic attack
Frequent fear of having a panic attack
Fear of having a panic attack all the time
8. How strong was this “fear of fear”?
9. Disability in family relationships (partnership, children etc.)
10. Disability in social relationships and leisure time (social events like cinema etc.)
11. Disability in employment (or housework).
12. Worries about health damage. Patient was worried about suffering bodily damage due to the disorder.
13. Assumption of organic disease. Patient thought that his anxiety symptoms are due to a somatic and not to a psychological disorder.
Not true, psychological disorder
Definitely true, somatic disorder
The presented answer sheet is not an original form and is not intended for printing or use as a handout.