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 year (4 digits)
Name of therapist (primary therapist)
Filled out by

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.

Was at least one panic attack unexpected, as if it came out of the blue?
Did it happen more than once?
If NO to questions 2 and 3 please leave the remainder of this questionnnaire blank, otherwise continue.

Have you ever worried a lot (for at least one month) about having another panic attack?

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.?

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?:

Shortness of breath or smothering sensations?
Feeling dizzy, unsteady, lightheaded, or faint?
Palpitations, pounding heart, or rapid heart rate?
Trembling or shaking?
Feelings of choking?
Nausea or abdominal distress?
Numbness or tingling sensations?
Flushes (hot flashes) or chills
Chest pain or discomfort?
Fear of dying?
Fear of going crazy or doing something uncontrolled?

How much do these symptoms interfere with your daily functioning?
How distressing do you find these symptoms?
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?
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)?
Have you ever been diagnosed with a medical problem (hyperthyroidism, a seizure or cardiac condition, etc.) that could have caused your panic symptoms?