Panic/Anxiety Symptom Evaluation Form
 
The following symptoms of Panic/Anxiety Disorder are listed as being typical. This information is being collected to determine the effectiveness of the product provided to you.
   
Please evaluate each symptom using the following scale:
0= Not at all    1= Just a little    2= Somewhat    3= Very much

Name :  
Date :  
Symptoms Sun Mon Tues Wed Thu Fri Sat
Shaking or trembling
             
Experiencing terror or fear of dying
             
A feeling of being out of control
             
Sweating
             
Have you actively avoided normal activities in order to prevent a panic attack today?
             
Intense concern in a relatively relaxed situation
             
Irritability
             
General feeling of depression
             
Lack of concentration / feelings of unreality or "brain fog"
             
Inability to sleep
             
Shortness of breath or a feeling of smothering, choking, tingling, or numbness
             
Heart racing or pounding and / or chest pains
             
Inability to relax / trouble falling asleep
             
Light-headedness or dizziness
             
Excessive worry
             
Frequent bathroom visits and / or nausea or stomach problems              
Supplement dosage, sleep, and medication  
Empower daily dosage (# of capsules)              
Hours of sleep              
Drug 1 daily dosage
Name:
              
Drug 2 daily dosage
Name:		              
Drug 3: daily dosage
Name:		              
Drug 4: daily dosage
Name:		              
Drug 5: daily dosage
Name:		              

Comments  
 
 
 
 
   
*Please send completed forms to Truehope Nutritional Support Ltd.
Ph: 1-888-TRUEHOPE (1-888-878-3467)
Fax: 1-888-752-7212
Email: sef@truehope.com
Mail: P.O. Box 888, Raymond, Alberta, Canada, T0K 2S0

Copyright © 2002 Truehope Nutritional Support Ltd.
Revised October 11, 2002