Panic Attacks Assessment Questionnaire - Grassroot Psychiatry Mental Health Clinic

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Grassroot Psychiatry Mental Health Clinic

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Panic Attacks Assessment Questionnaire

Are you troubled by the following?

Patient Name *

Phone Number *

Email Address *

If yes, during an attack did you experience any of these symptoms?YesNo

Pounding heartYesNo

SweatingYesNo

Trembling or shakingYesNo

Shortness of breathYesNo

ChokingYesNo

Chest painYesNo

Nausea or abdominal discomfortYesNo

"Jelly" legsYesNo

DizzinessYesNo

Fear of losing control or "going crazy"YesNo

Fear of dyingYesNo

Numbness or tingling sensationsYesNo

Chills or hot flushesYesNo

As a result of these attacks, have you experienced a fear of places or situations where getting help or escape might be difficult, such as in a crowd or on a bridge?YesNo

As a result of these attacks, have you felt unable to travel without a companion?YesNo

For at least one month following an attack, have you felt persistent concern about having another one?YesNo

For at least one month following an attack, have you worried about having a heart attack or “going crazy”?YesNo

For at least one month following an attack, have you changed your behavior to accommodate the attack?YesNo

Have you experienced changes in sleeping or eating habits?YesNo

More days than not, do you feel sad or depressed?YesNo

More days than not, do you feel disinterested in life?YesNo

More days than not, do you feel worthless or guilty?YesNo

During the last year, has the use of alcohol or drugs resulted in your failure to fulfill responsibilities with work, school, or family?YesNo

During the last year, has the use of alcohol or drugs placed you in a dangerous situation, such as driving a car under the influence?YesNo

During the last year, has the use of alcohol or drugs gotten you arrested?YesNo

During the last year, has the use of alcohol or drugs continued despite causing problems for you or your loved ones?YesNo

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Grassroot psychiatry and mental health clinic PLLC

Location

2100 N high way 360 suit 405b Grand Prairie TX 75050.

Contact

Email: info@grpmhc.com
Phone: +1 6824536176

Provider

Martina Onah Ezigbo (PMHNP-BC)

Services

Anxieties, Depression, Panic attacks, ADHD, Psychosis, PTSD, etc.

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