This is a 20 question survey for patients to fill out for any nose or sinus issues.

Please answer these questions twice. Once Before and once After any procedure.

Please rate the severity of your condition on each of the 20 items using a 0-5 category rating system: On a scale of 0-5, rate your symptoms.

0 = No Problem
1 = Very Mild Problem
2 = Mild or Slight Problem
3 = Moderate Problem
4 = Severe Problem
5 = As Bad As It Can Be

1. Need to blow nose

      

2. Sneezing

      

3. Runny nose

      

4. Cough

      

5. Postnasal discharge (dripping at the back of your throat)

      

6. Thick nasal discharge (snot)

      

7. Ear fullness

      

8. Dizziness

      

9. Ear pain

      

10. Facial pain/pressure

      

11. Difficulty falling asleep

      

12. Waking up at night

      

13. Lack of a good night’s sleep

      

14. Waking up tired

      

15. Fatigue

      

16. Reduced productivity

      

17. Reduced concentration

      

18. Frustrated/restless/irritable

      

19. Sad

      

20. Embarrassed

      

 

 


 

Score

Evaluation

Recommended Next Step

0 to 10

No problem to mild problem No actions necessary or symptoms can be treated with OTC medication.

11 to 40

Moderate problem An appointment with a sinus specialist is recommended and/or prescription medicine can be taken to treat symptoms.

41 to 69

Moderate to severe An appointment with a specialist is recommended and/or prescription medicine can be taken to treat symptoms. You may benefit from balloon sinuplasty or surgery.

70 to 100

Severe to “as bad as it can be” An appointment with a specialist is recommended, treatment to be determined by doctor. Possible surgical candidate.
*The SNOT score evaluation is to be used as a guide and not a physician’s diagnosis. Treatment to be determined by doctor upon appointment.

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