Questionnaire First name(Required)Your email address:(Required)Your age:CountrySelect countryAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweTime zoneSelect time zoneHawaii — HonoluluAlaska — AnchoragePacific Time — Los AngelesMountain Time — DenverCentral Time — ChicagoEastern Time — New YorkAtlantic Time — HalifaxBrazil — São PauloUnited Kingdom — LondonCentral Europe — Paris / BerlinEastern Europe — AthensSouth Africa — JohannesburgEgypt — CairoUnited Arab Emirates — DubaiPakistan — KarachiIndia — KolkataNepal — KathmanduBangladesh — DhakaThailand — BangkokSingaporeHong KongChina — ShanghaiJapan — TokyoSouth Korea — SeoulWestern Australia — PerthNorthern Territory — DarwinSouth Australia — AdelaideEastern Australia — SydneyNew Zealand — AucklandOn a typical day, what is your average level of anxiety, with "0" being completely calm and peaceful, and "10" being a panic attack?In the last week, about how many panic attacks have you experienced?In the last month, about how many panic attacks?Do you believe a panic attack can be dangerous? Yes No Not Sure During a panic attack, what do you do that helps you cope?Which of the following are "triggers" for panic for you: Traveling far from home by yourself Going to a crowded restaurant Taking an elevator up 10 stories Going on an airplane trip Which of the following are among your top fears: Being embarrassed in a social situation Being watched closely when doing something Being the center of attention Do you often avoid social events or social situations? Yes No Tell me a little about how your activities are restricted by your condition:What do you think is your correct diagnosis?About how long ago did this condition start?What other psychological or physical conditions do you have?What medications are you currently taking?Have you tried medications in the past that you are not taking now? If yes, tell me a little about your experience.Are you currently in therapy? Yes No If yes, tell me a little about it:Have you had any experience with cognitive-behavioral therapy (CBT)? Yes No If yes, tell me a little about it:How healthy is your diet? Very Healthy Better then average Average diet Worse then Average About how much caffeine do you drink in a typical day?SelectNoneEquivalent of one cup of tea or one soft drinkEquivalent of one cup of coffeeTwo cups of coffee3 to 4 cups of coffeeMore than 4 cups of coffeeAbout how much alcohol do you drink in a typical day?SelectNoneOne drink (equal to one beer or one glass of wine)Two drinks3 to 4 drinksMore than 4 drinksDo you smoke or vape? Yes No Do you do any regular exercise? Yes No If yes, tell me about it:Do you practice meditation or use a relaxation method? Yes No If yes, what do you find helpful?What is the quality of your sleep? Good Sometimes good, Sometimes not very good Poor Any comments to add about your sleep?What are some of your sources of emotional support? Spouse or lover Friends & family Therapist Church, synagogue or mosque Online support groups Who is in your household (single, spouse or partner, children, parents, etc.)?What are some of your main activities during the day (work, childcare, school, etc.)?What "big life issues," if any, do you think may be relevant? Examples of "big life issues" are: traumatic events, loss or illness of a loved one, separation or divorce, job change, or moving to a new city.Is there anything you'd like to add?
