In the last month have you often been bothered by any of these problems?

1. ___ Feeling restless, hard to sit still?
2. ___ Getting tired easily?
3. ___ Muscle tension, aches, soreness?
4.___  Trouble falling asleep or staying asleep?
5.___  Trouble concentrating on things, such as reading or watching TV?
6.___  Becoming easily annoyed or irritated?

Are two or more of #1 to 6 checked?

7. In the last month, have these problems made it hard for you to do your work, take care of things at home, or get along with others?                                                                                                                                                       Yes   No

8. In the last month, have you been worrying a great deal? (Yes--only if more than half of days in last month.)     Yes   No

9.  Have you had all of these problems for as long as 6 months?                                                                      Yes   No

If 7, 8 & 9 are No then

1.     Have you had four attacks within a 4 week period?        Yes    No
        Are you afraid of having another attack?                       Yes    No  (If these are no, you may stop here.)
 
2.     Does the attack come out of the blue?                         Yes    No

During the last Panic attack did you have:

  3.    ___shortness of breath?
  4.    ___a racing, pounding or skipping heart?
  5.    ___chest pain or pressure?
  6.    ___sweating?
  7.    ___the feeling of choking?
  8.    ___hot flashes or chills?
  9.    ___nausea, upset stomach? Or feeling you were going to have diarrhea?
10.    ___dizziness, unsteadiness, or faintness?
11.    ___numbness in parts of your body?
12.    ___trembling or shaking
13.    ___the feeling things around you were unreal?
14.    ___fear that you were dying?
15.    ___fear that you were going crazy or might do something out of control?

Are four or more of # 3 through 15 checked?