Template library · Assessments & screeners
Panic Disorder Screen template
Ask about episodes of sudden, intense fear or discomfort in the past month.
Structured screen for panic attack symptoms
- 24 fields across 4 sections
- Included with MyWellOps
- Edit it, or save your own version
What’s in it
Assessment Details
- Client NameText
- Date of BirthDate
- Client ID / MRNText
- Date of AssessmentDate
- Clinician / CoachText
- Location / ModalityText
Panic Symptoms Endorsed
- Racing or pounding heartTick box
- SweatingTick box
- Trembling or shakingTick box
- Shortness of breathTick box
- Choking sensationTick box
- Chest pain or discomfortTick box
- Nausea or abdominal distressTick box
- Dizziness or lightheadednessTick box
- Fear of losing control or dyingTick box
- Numbness or tinglingTick box
Episode History
- Frequency and duration of episodesText
- Known or suspected triggersText
- Avoidance behaviors developedText
- Impact on daily functioningText
Signatures
- Clinician SignatureSignature
- Date signed (clinician)Date
- Client SignatureSignature
- Date signed (client)Date
When to use it
Use an assessment at the start of work to set a baseline, then repeat it at review points so you and the client can see what has changed.
How it works in MyWellOps
- Pick it from Documents.
- Send it to the client to complete, or fill it in together during a session.
- Each completed copy is kept on the client’s record, so earlier results are there to compare.
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