PDSR
Your birthdate and date of your first DBTCSD therapy session are needed for us to identify your data while keeping it anonymous to others. Your data will be transmitted securely as scrambled numbers without any text labels.
Birthday
Jan 1
Feb 2
Mar 3
Apr 4
May 5
Jun 6
July 7
Aug 8
Sep 9
Oct 10
Nov 11
Dec 12
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
year (4 digits)
Name of therapist
Gutierrez
Dahlin
Langlois
Jay Weingarten
Brown
Contreras
Tuesday Group
Wednesday Group
Thursday Group
Other
(primary therapist)
Filled out by
client
parent
other
No
Yes
During the last six months, have you had a panic attack or a sudden rush of intense fear or anxiety?
If NO (you have not experienced a panic attack), click "N/A" for questions 2 and 3 and leave the remainder of this questionnnaire blank.
If YES, please continue.
No
Yes
N/A
Was at least one panic attack unexpected, as if it came out of the blue?
No
Yes
N/A
Did it happen more than once?
If NO to questions 2 and 3 please leave the remainder of this questionnnaire blank, otherwise continue.
No
Yes
Have you ever worried a lot (for at least one month) about having another panic attack?
No
Yes
Have you ever worried a lot (at least one month) that having the attacks meant you were losing control, going crazy, having a heart attack, seriously ill, etc.?
No
Yes
Did you ever change your behavior or do something different (for at least one month) because of the attacks?
If YES to 5, 6 OR 7 please answer the following questions:
Think back to your most severe panic attack. Did you experience any of the following symptoms?:
No
Yes
Shortness of breath or smothering sensations?
No
Yes
Feeling dizzy, unsteady, lightheaded, or faint?
No
Yes
Palpitations, pounding heart, or rapid heart rate?
No
Yes
Trembling or shaking?
No
Yes
Sweating?
No
Yes
Feelings of choking?
No
Yes
Nausea or abdominal distress?
No
Yes
Numbness or tingling sensations?
No
Yes
Flushes (hot flashes) or chills
No
Yes
Chest pain or discomfort?
No
Yes
Fear of dying?
No
Yes
Fear of going crazy or doing something uncontrolled?
0 - Not at All
1
2 - Mildly
3
4 - Moderately
5
6 - Severely
7
8 - Very Severely
How much do these symptoms interfere with your daily functioning?
0 - Not at All
1
2 - Mildly
3
4 - Moderately
5
6 - Severely
7
8 - Very Severely
How distressing do you find these symptoms?
No
Yes
When you have bad panic attacks, does it often take
less than ten minutes
from the point at which the attack begins, to the point at which it reaches a peak or becomes most intense?
No
Yes
Just before you began having panic attacks, were you taking any drugs or excessive amounts (more than 4 cups daily) of stimulants (e.g., coffee, tea, or cola with caffeine)?
No
Yes
Have you ever been diagnosed with a medical problem (hyperthyroidism, a seizure or cardiac condition, etc.) that could have caused your panic symptoms?
MC
PB
AG
JL
KD
MM
ALB
MZB