Agoraphobia (DSM-5 Assessment)
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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)