Panic Disorder Screening Questionnaire Form
Complete this screening questionnaire to help document panic symptoms, their frequency, and whether follow-up support is desired. The form uses a calm, premium layout with generous spacing and a polished modern style.
Respondent Details
Respondent Name
*
Preferred Contact Email
*
example@example.com
Age
*
Preferred Contact Method
*
Email
Phone
Text Message
Other
Panic Symptom Screening
How often have you had panic attacks?
*
Never
Rarely (less than monthly)
Sometimes (monthly)
Often (weekly)
Very often (multiple times per week)
Were the episodes unexpected or triggered by specific situations?
*
Mostly unexpected
Mostly triggered by specific situations
Both unexpected and triggered
Not sure
Which symptoms did you experience during episodes?
*
Heart racing or pounding
Sweating
Trembling or shaking
Shortness of breath
Choking sensation
Chest discomfort
Nausea or stomach upset
Dizziness or lightheadedness
Feeling unreal or detached
Fear of losing control
Fear of dying
Numbness or tingling
Chills or hot flushes
Other
How frequently do these symptoms occur during panic episodes?
*
Rarely
1
2
3
4
5
6
7
8
9
Very frequently
10
1 is Rarely, 10 is Very frequently
Impact and Follow-up
When did these symptoms begin, or how long have they been happening?
Would you like follow-up support or a results discussion?
*
Yes, follow-up support
Yes, discuss results
No, not at this time
Submit Screening
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