Dr. Prajoy Kadkade | NYENTDOC.COM
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Below you will find a list of symptoms and social/emotional consequences of your rhinosinusitis. We would like to know more about these problems and would appreciate your answering the following questions to the best of your ability. There are no right or wrong answers, and only you can provide us with this information. Please rate your problems as they have been over the past two weeks. Thank you for your participation. Do not hesitate to ask for assistance if necessary.
Considering how severe the problem is when you experience it and how often it happens, please rate each item below on how “bad” it is by circling the number that corresponds with how you feel using this scale:
0: No problem 1: Very Mild Problem 2: Mild or slight Problem 3: Moderate Problem 4: Severe Problem 5: Problem as bad as it can be
Need to blow nose: 012345 Nasal Blockage: 012345 Sneezing: 012345 Runny nose: 012345 Cough: 012345 Post-nasal discharge: 012345 Thick nasal discharge: 012345 Ear fullness: 012345 Dizziness: 012345 Ear pain: 012345 Facial pain/pressure: 012345 Decreased Sense of Smell/Taste: 012345 Difficulty falling asleep: 012345 Wake up at night: 012345 Lack of a good night’s sleep: 012345 Wake up tired: 012345 Fatigue: 012345 Reduced productivity: 012345 Reduced concentration: 012345 Frustrated/restless/irritable: 012345 Sad: 012345 Embarrassed: 012345
Total: [calculator calculator-191 “blow-nose + nasal-blockage + sneezing + runny-nose + cough-nose + post-discharge + thick-discharge + ear-fullness + dizziness + ear-pain + facial-pain + decreased-smell + falling-asleep + wake-up-night + lack-sleep + wake-tired + fatigue + reduced-pro + reduced-con + frustrated + sad + embarassed”]
Please mark the most important items affecting your health (maximum of 5 items):Need to blow noseNasal BlockageSneezingRunny noseCoughPost-nasal dischargeThick nasal dischargeEar fullnessDizzinessEar painFacial pain/pressureDecreased Sense of Smell/TasteDifficulty falling asleepWake up at nightLack of a good night’s sleepWake up tiredFatigueReduced productivityReduced concentrationFrustrated/restless/irritableSadEmbarrassed
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