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Anxiety and Panic Attacks In Emphysema ... - Mind Publications

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Name<br />

Date<br />

DR. SHARMA’S ANXIETY CHECKLIST<br />

(Adapted from DSM-IV, Beck, Burns <strong>Anxiety</strong> <strong>In</strong>ventories)<br />

Please rate each symptom by putting (x) mark to indicate how bothered (“none”, “mild”,<br />

“moderate”, or “severe”)<br />

you have been by these symptoms in the past 2 weeks, including today.<br />

SWEATING/COLD SWEAT/BREAK INTO SWEAT (not due to<br />

heat)<br />

TREMBLING/SHAKING<br />

HOT FLASHES/COLD CHILLS<br />

NAUSEA/ABDOMINAL DISTRESS/BUTTERFLIES<br />

PALPITATION/ HEART RACING OR POUNDING<br />

SHORTNESS OF BREATH/SMOTHERING/CAN’T GET AIR<br />

UNSTEADINESS/DIZZINESS/FAINTING/LIGHTHEADEDNESS<br />

TINGLING/NUMBNESS<br />

CHEST PAINS/TIGHTNESS/PRESSURE<br />

CHOKING<br />

FEELING OF UNREALITY<br />

FEEL THINGS CHANGE SIZE<br />

FEEL BODY CHANGES SIZE<br />

THINGS APPEAR STRANGE<br />

FEEL DETACHED FROM SELF<br />

FEAR OF DYING<br />

FEAR OF GOING CRAZY/LOSING CONTROL<br />

RINGING IN EARS<br />

VOICES FADING OR THINGS BECOMING DISTANT<br />

MUSCLE TENSION/ACHES/SORENESS<br />

RESTLESSNESS/JUMPINESS<br />

EASY FATIGUABILITY/FEELING WEAK/EASILY<br />

EXHAUSTED<br />

EXAGGERATED STARTLE RESPONSE<br />

FREQUENT URINATION<br />

TROUBLE SWALLOWING/”LUMP IN THROAT)<br />

DRY MOUTH/LIKE COTTON (Not due to medicine)<br />

FEELING KEYED UP/ ON EDGE”<br />

IRRITABILITY<br />

non<br />

e<br />

0<br />

mil<br />

d<br />

1<br />

moder<br />

ate<br />

2<br />

seve<br />

re<br />

3

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