Agoraphobia (DSM-5 Assessment)
You can respond anonymously, and no data will be retained from this assessment. If you choose to include your initials and an email address, your results will be automatically sent to the email address provided. Please check that the email address has been entered correctly before submitting this form. All client information is managed on a strictly confidential basis. Please Note: Whilst every effort is made to ensure that our system is securely encrypted, email is not a completely secure means of communication. Think CBT does not accept liability for loss or theft of personal data where any individual chooses to transmit or receive information via email.
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This questionnaire is not designed to provide a definitive psychological diagnosis or to take the place of a professional consultation. Please answer all questions as accurately and honestly as possible.

Instructions

The following questions ask about thoughts, feelings, and behaviors you may have had in the following situations: crowds, public places, using transportation (e.g., buses, planes, trains), traveling alone, or away from home.

Please respond to each item by marking one box per row.

During the last 7 days, I have....


1. felt moments of sudden terror, fear, or fright in these situations





2. felt anxious, worried, or nervous about these situations





3. had thoughts about panic attacks, uncomfortable physical sensations, getting lost, or being overcome with fear in these situations





4. felt a racing heart, sweaty, trouble breathing, faint, or shaky in these situations





5. felt tense muscles, felt on edge or restless, or had trouble relaxing in these situations





6. avoided, or did not approach or enter, these situations





7. moved away from these situations, left them early, or remained close to the exits





8. spent a lot of time preparing for, or procrastinating about (putting off), these situations





9. distracted myself to avoid thinking about these situations





10. needed help to cope with these situations (e.g., alcohol or medication, superstitious objects, other people)