Panic Attack Screening

Name *

First Name

Last Name

Phone

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Panic Attack Assessment *

Check all that apply if you have experienced any of the following:

Intense feelings of doom and gloom

Racing heart

Lightheadedness

Heart palpitations

Sweating

Nervous stomach

Trembling

Feeling like you are about to lose control

Feeling like you are about to go crazy

Feeling overwhelmed

Sudden and strong urge to escape

Heightened fear and apprehension

Increase stimulation

Pins and needles

Throat tightness

Muscle weakness

Weak in the knees

Super sensitive senses and nerves