Online Sinus Questionnaire

Below you will find a list of symptoms and social/emotional consequences typically associated with sinus issues.  There are no right or wrong answers, so make sure to provide the most honest answers for yourself. Please rate your problems, as they have been over the past two weeks.

Thank you for taking the time to visit www.sinusreliefny.com and please contact us at 845-360-9197 with any questions you may have.

Considering how severe the problem is when you experience it and how frequently it happens, please rate each item below on how ‘bad’ it is by selecting the number that corresponds with how you feel using this scale:

1. Need to blow nose

 0

 1

 2

 3

 4

 5

2. Sneezing

 0

 1

 2

 3

 4

 5

3. Runny nose

 0

 1

 2

 3

 4

 5

4. Cough

 0

 1

 2

 3

 4

 5

5. Post nasal discharge

 0

 1

 2

 3

 4

 5

6. Thick nasal discharge

 0

 1

 2

 3

 4

 5

7. Ear fullness

 0

 1

 2

 3

 4

 5

8. Dizziness

 0

 1

 2

 3

 4

 5

9. Ear pain

 0

 1

 2

 3

 4

 5

10. Facial pain/pressure

 0

 1

 2

 3

 4

 5

11. Difficulty falling asleep

 0

 1

 2

 3

 4

 5

12. Wake up at night

 0

 1

 2

 3

 4

 5

13. Lack of a good night’s sleep

 0

 1

 2

 3

 4

 5

14. Wake up tired

 0

 1

 2

 3

 4

 5

15. Fatigue

 0

 1

 2

 3

 4

 5

16. Reduced productivity

 0

 1

 2

 3

 4

 5

17. Reduced concentration

 0

 1

 2

 3

 4

 5

18. Frustrated/restless/irritable

 0

 1

 2

 3

 4

 5

19. Sad

 0

 1

 2

 3

 4

 5

20. Embarrassed

 0

 1

 2

 3

 4

 5

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