Please print and then complete the following:
1. When was your first panic attack?
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2. Where were you?
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3. What were you doing?
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4. Were you alone or with someone else?
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5. Were you facing any life challenges or changes at the time?
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6. Had you experienced any recent losses or deaths?
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7. Had you experienced any medical concerns?
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8. Did you fear you might have a medical crisis or die at the time of the panic
attack?
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9. Did you fear you might lose control of yourself or go crazy?
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10. Did you fear social humiliation?
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11. What symptoms did you experience?
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