Panic and Agoraphobia Questionnaire Pack

PHQ- 9
Over the last 2 weeks, how often have you been bothered by any More Nearly
Several
of the following problems? Not at all than half every
days
the days day
1 Little interest or pleasure in doing things 0 1 2 3
2 Feeling down, depressed, or hopeless 0 1 2 3

3 Trouble falling or staying asleep, or sleeping too much 0 1 2 3

4 Feeling tired or having little energy 0 1 2 3

5 Poor appetite or overeating 0 1 2 3

Feeling bad about yourself or that you are a failure or have let
6 0 1 2 3
yourself or your family down
Trouble concentrating on things, such as reading the newspaper or
7 0 1 2 3
watching television
Moving or speaking so slowly that other people could have noticed?
8 Or the opposite being so fidgety or restless that you have been 0 1 2 3
moving around a lot more than usual
Thoughts that you would be better off dead or of hurting yourself in
9 0 1 2 3
some way
A11 PHQ9 total score

GAD-7
Over the last 2 weeks, how often have you been bothered by any More Nearly
Several
of the following problems? Not at all than half every
days
the days day

1 Feeling nervous, anxious or on edge 0 1 2 3

2 Not being able to stop or control worrying 0 1 2 3

3 Worrying too much about different things 0 1 2 3

4 Trouble relaxing 0 1 2 3
5 Being so restless that it is hard to sit still 0 1 2 3

6 Becoming easily annoyed or irritable 0 1 2 3

7 Feeling afraid as if something awful might happen 0 1 2 3

A12 GAD7 total score

IAPT Phobia Scales
Choose a number from the scale below to show how much you would avoid each of the situations or objects
listed below. Then write the number in the box opposite the situation.
0 1 2 3 4 5 6 7 8
Would not Slightly Definitely Markedly Always avoid
avoid it avoid it avoid it avoid it it

A17 Social situations due to a fear of being embarrassed or making a fool of myself

Certain situations because of a fear of having a panic attack or other distressing symptoms (such
A18
as loss of bladder control, vomiting or dizziness)

Certain situations because of a fear of particular objects or activities (such as animals, heights,
A19
seeing blood, being in confined spaces, driving or flying).
IAPT Employment Status Questions
A13 - Please indicate which of the following options best describes your current status:

Employed full-time (30 hours or more per week)

Employed part-time
Unemployed
Full-time student
Retired
Full-time homemaker or carer

A14 - Are you currently receiving Statutory Sick Pay?

Yes
No

A15 - Are you currently receiving Job Seekers Allowance, Income support or Incapacity benefit?

Yes
No

Work and Social Adjustment

People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your
problems look at each section and determine on the scale provided how much your problem impairs
your ability to carry out the activity.

1. WORK - if you are retired or choose not to have a job for reasons unrelated to your problem, please
tick N/A (not applicable)

0 1 2 3 4 5 6 7 8 N/A
Not at Slightly Definitely Markedly Very severely,
all I cannot work

2. HOME MANAGEMENT Cleaning, tidying, shopping, cooking, looking after home/children, paying
bills etc

0 1 2 3 4 5 6 7 8
Not at Slightly Definitely Markedly Very severely
all

3. SOCIAL LEISURE ACTIVITIES - With other people, e.g. parties, pubs, outings, entertaining etc.

0 1 2 3 4 5 6 7 8
Not at Slightly Definitely Markedly Very severely
all

4. PRIVATE LEISURE ACTIVITIES Done alone, e.g. reading, gardening, sewing, hobbies, walking
etc.

0 1 2 3 4 5 6 7 8
Not at Slightly Definitely Markedly Very severely
all

5. FAMILY AND RELATIONSHIPS Form and maintain close relationships with others including the
people that I live with

0 1 2 3 4 5 6 7 8
Not at Slightly Definitely Markedly Very severely
all

A14 W&SAS total

score
 The Mobility Inventory (MI)
Please indicate the degree to which you avoid the following places or situations because of discomfort
or anxiety. Rate your amount of avoidance when you are with a trusted companion and when you are
alone. Do this by using the following scale.
1. Never avoid
2. Rarely avoid
3. Avoid about half the time
4. Avoid most of the time
5. Always avoid
(You may use numbers half-way between those listed when you think it is appropriate. For example, 3
or 4 ). Write your score in the blanks for each situation or place under both conditions: when
accompanied, and, when alone. Leave blank those situations that do not apply to you.

Place When accompanied When alone

Theatres... ... ... ... _____ ... ... _____

Supermarkets ... ... ... ... _____ ... ... _____
Classrooms ... ... ... ... _____ ... ... _____
Department stores ... ... ... _____ ... ... _____
Restaurants ... ... ... ... _____ ... ... _____
Museums ... ... ... ... _____ ... ... _____
Elevators/Lifts ... ... ... ... _____ ... ... _____
Auditoriums or stadiums ... ... _____ ... ... _____
Car parks ... ... ... ... _____ ... ... _____
High places ... ... ... ... _____ ... ... _____
Tell how high ..........
Enclosed spaces (e.g. tunnels) ... ... _____ ... ... _____
Open spaces:
(A) Outside (e.g. fields, wide streets, courtyards) _____ ... ... _____
(B) Inside (e.g. large rooms, lobbies) _____ ... ... _____
RIDING IN:
Buses ... ... ... ... _____ ... ... _____
Trains ... ... ... ... _____ ... ... _____
Underground/Tubes ... ... ... _____ ... ... _____
Airplanes ... ... ... ... _____ ... ... _____
Boats ... ... ... ... _____ ... ... _____
Driving or riding in a car:
(A) At any time ... ... _____ ... ... _____
(B) On motorways ... ... _____ ... ... _____
SITUATIONS:
Standing in lines ... ... ... _____ ... ... _____
Crossing bridges ... ... ... _____ ... ... _____
Parties or social gatherings ... ... _____ ... ... _____
Walking on the street ... ... ... _____ ... ... _____
Staying at home alone ... ... ... X ... ... ... _____
Being far away from home ... ... _____ ... ... _____
Other (specify) ............................. ... _____ ... ... _____
 Agoraphobic Cognitions Questionnaire

This questionnaire has two parts. Below are some thoughts or ideas that may go through your mind
when you are nervous or frightened. Indicate how often each thought occurs when you are nervous;
rate each thought from 1-5 using the scale below; put your rating on the LEFT hand side of each item.

1. Thought never occurs

2. Thought rarely occurs
3. Thought occurs during half of the times when I am nervous
4. Thought usually occurs
5. Thought always occurs when I am nervous

How Often Believe

1) ___ I am going to throw up ___

2) ___ I am going to pass out ___

3) ___ I must have a brain tumour ___

4) ___ I will have a heart attack ___

5) ___ I will choke to death ___

6) ___ I am going to act foolish ___

7) ___ I am going blind ___

8) ___ I will not be able to control myself ___

9) ___ I will lose control of my bladder or bowels ___

10) ___ I will hurt someone ___

11) ___ I am going to have a stroke ___

12) ___ I am going to go crazy ___

13) ___ I am going to scream ___

14) ___ I am going to babble or talk funny ___

15) ___ I will be paralysed with fear ___

16) ___ I am about to die ___

17) ___ I am seriously ill ___

18) ___ I am going to suffocate ___

Other ideas not listed (please describe and rate):

___ ___
___ ___
When you have the symptoms of panic, how much would you believe each of these thoughts to be true.
Go back and rate each thought by choosing a number from the scale below, and put the number which
applies on the dotted line on the RIGHT hand side of the form.

0 10 20 30 40 50 60 70 80 90 100
I do not believe I am completely convinced
this thought at all this thought is true

Finally, please rate the item below in the way you have done for the individual thoughts above;
remember that the harm might include one or more of the thoughts listed above.

19) ___ In a panic attack, I will suffer serious physical or mental harm ___
 PANIC RATING SCALE (P)

A panic attack means a sudden increase in anxiety during which four or more of the following sensations
are experienced:
1. Feeling short of breath 2. Palpitations or heart racing
3. Choking 4. Chest feeling uncomfortable or painful
5. Sweating 6. Dizziness, unsteady feelings or faintness
7. Feeling unreal or detached from yourself 8. Nausea or discomfort in the stomach
9. Hot or cold flushes 10. Trembling or shaking
11. Numbness or tingling feelings (pins and needles) 12. Fear of dying
13. Fear of doing something uncontrolled or going crazy during an attack

Please circle a number on each of the scales below to indicate your answer:

1. What was the frequency of your panic attacks during the last two weeks?

0 1 2 3 4
No panic One panic One or two At least three panic One or more panic
attacks attack per panic attacks attacks per week but attacks per day
fortnight per week averaging less than one
per day

2. How severe a problem are panic attacks for you at present??

0 1 2 3 4 5 6 7 8
Not at all Slightly Definitely Markedly Very disturbing
disturbing disturbing disturbing disturbing and/or disabling
and/or and/or and/or and/or
disabling disabling disabling disabling

3. In the past two weeks, how much have you avoided situations (or needed someone to accompany
you) due to fear that you may panic/ have symptoms? Examples are: being outside home alone,
travelling, being in a crowd, supermarket or department store?

0 1 2 3 4 5 6 7 8
Never Occasionally Moderate Severe Always
avoid avoid avoidance avoidance avoid