Daily Panic Attack Tracking Sheet

Patient Information

Name: ___________________ Date: ___________________

Episode Details

Time and Duration

• Time episode began: __________ AM/PM
• Duration: __________ minutes
• Location when episode occurred: __________________

Trigger Identification

• What were you doing when it started? __________________
• What were you thinking about? __________________
• Recent stressors (if any): __________________

Symptoms Experienced (check all that apply)

□ Rapid heartbeat □ Shortness of breath □ Chest pain/tightness □ Sweating □ Trembling/shaking □ Nausea □ Dizziness □ Numbness/tingling □ Fear of losing control □ Fear of dying □ Feeling of unreality □ Other: __________________

Intensity Rating

Rate the intensity of your panic attack (circle one): 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10 (1 = mild, 10 = severe)

Coping Strategies Used

□ Deep breathing □ Progressive muscle relaxation □ Grounding techniques □ Called support person □ Took prescribed medication □ Other: __________________

Effectiveness of Coping Strategies

Rate how well coping strategies worked (circle one): 1 - 2 - 3 - 4 - 5 (1 = not effective, 5 = very effective)

Additional Notes

Bring this completed form to your next therapy session.