Here are some questions about your health. Check either YES or NO to indicate your answer.
Click the button below to start.
Question 1 of 5
Do you fear or avoid certain situations because you fear having panic-like symptoms or other incapacitating or embarrassing symptoms?
Yes
No
Question 2 of 5
Check the following environments or situations that you avoid due to fear, anxiety or discomfort:
Using public transportation (e.g., cars, buses, trains, subway, ships or planes)
Being in open spaces (e.g., parking lots, marketplaces or malls, or bridges)
Being in enclosed spaces (e.g., shops, theaters, cinemas, conference rooms or classrooms)
Standing in line or being in a crowd (e.g., concerts, sporting arenas, public attractions)
Being outside of the home or away from your safe place alone
Question 3 of 5
Do you fear or avoid situations and environments where you fear that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms?
Question 4 of 5
Does being in your feared or (agoraphobic) situations almost always provoke fear or anxiety?
Question 5 of 5
Check the following descriptions that apply to you:
I actively avoid my ”agoraphobic” or uncomfortable situations
I can endure my “agoraphobic” situation with a companion
I can endure my “agoraphobic” situation but experience intense fear or anxiety