Dr. Prajoy Kadkade | NYENTDOC.COM


Please complete the following survey if you are having problems with nose and/or sinus problem.

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

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