Current Age:

Age when Panic began:

Where was first Panic Attack:

What kind of medications have you tried:

How long on that Medication:

What kind of medication are you currently on:

How long on current medication:

Other Information:

Have you had Cognitive Behavioral Therapy?: Yes No

Have you had regular Therapy?: Yes No

Current Level of Panic: (Where 1 is the mildest and 10 is the strongest Level)

1 2 3 4 5 6 7 8 9 10

Are you sensitive to Heat?: Yes No

Are you sensitive to Cold?: Yes No