Agoraphobic cognitions questionnaire

Below are some thought or ideas that may pass through your mind when you are nervous or frightened. Please indicate how often each thought occurs when you are nervous. Rate from 1-5 using the scale below:

1 Thought Never Occurs

2 Thought Rarely occurs

3 Thought occurs During half of the times

4 Thought Usually Occurs

5 Thought Always occurs

When I am nervous ….

1. I am going to throw up	1	2	3	4	5
2. I am going to pass out
3. I must have a brain tumor
4. I will have a heart attack
5. I will chock to death
6. I am going to act foolish
7. I am going blind
8. I will not be able to control my self
9. I will lose control of my bladder or bowels
10. I will hurt someone
11. I am going to have stroke
12. I am going crazy
13. I am going to scream
14. I am going to babble or talk funny
15. I will be paralysed with fear
16. I am about to die
17. I am seriously ill
18. I am going to suffocate
other ideas not listed (please describe and rate them)
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Copy right 1984‚ Dianne L. Chambless

When you have the symptoms of panic‚ how much would you believe each of these thoughts to be true. Go back and rate each thought by choosing a number from the scale below‚ and put the number which applies on the dotted line on the RIGHT hand side of the form.

0 I do not believe this thought at all

10

20

30

40

50

60

70

80

90

100 I am completely convinced this thought is true

Finally‚ please rate the item below in the way you have done for the individual thoughts above; remember that the harm might include one or more of the thoughts listed above.

19. in panic attack‚ I will suffer serious physical or mental harm

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