FORMATO DE REGISTRO DE PANICO I

FECHA: ________________ HORA: _____________ DURACION: ____________

CON:
PAREJA ( )
AMIGO ( )
SOLO ( )
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SITUACION ANSIOGENA: SI/NO, SI APARECE BREVE DESCRIPCION:
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ANSIEDAD MAXIMA (RODEE CON UN CIRCULO): 0 1 2 3 4 5 6 7 8 9 10
SENSACIONES (MARQUELAS):
TAQUICARDIA ( )
MAREO ( )
NAUSEAS ( )
PRESION EN EL PECHO ( )
COSQUILLEOS ( )
MIEDO A MORIR ( )
MIEDO A (DESCRIBIR):____________________________________________
OTRAS SENSACIONES:
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