Name: _________________________   Age: ___    Date: ______

 

Please circle any of the following treatments that you have received for your sinusitis within the last 3 months:

 

   [ ]  Saline nasal spray (“Ocean Spray”)

 

   [ ]  Steroid nasal spray (Vancenase, Beconase, Flonase, Nasacort, Nasonex, etc.)

 

   [ ]  Decongestant pills or spray (Afrin, Entex, Sudafed, etc.)

 

   [ ]  Antihistamines (Claritin, Astelin, Hismanal, Allegra, Zyrtec, Chlortrimeton,

        Benadryl, etc.)

 

   [ ]  Antibiotics

 

   1. Have you ever had previous sinus surgery                            [Yes]  [No]

 

   2. Do you have a sensation of pain or pressure in your face?           [Yes]  [No]

 

   3. Do you have a sensation of congestion or fullness in your face?     [Yes]  [No]

 

   4. Do you have trouble breathing through one or both of your nostrils? [Yes]  [No]

 

   5. Are you having yellow, brown, or green drainage from your nose?     [Yes]  [No]

 

   6. Have you been experiencing pain in your teeth?                      [Yes]  [No]

 

   7. Do you have diminished sense of small?                              [Yes]  [No]

 

   8. Do you have frequent headaches?                                     [Yes]  [No]

 

   9. Have you had a temperature of 101.5 degrees F

      measures with a thermometer) in the last 12 weeks?                  [Yes]  [No]

 

   10. Have you or has anyone close to you noticed you have a problem

       with bad breath?                                                   [Yes]  [No]

 

   11. Do you feel that you have more tired than usual lately?            [Yes]  [No]

 

   12. Do you have chronic cough?                                         [Yes]  [No]

 

   13. Do you have frequent earaches or a sensation of pressure or

       fullness in your ears?                                             [Yes]  [No]

 

   14. Have you ever  had a CT of your sinuses?

       If yes, when and where was the CT done? ________________________________

 

If you have answered “Yes” to any of the above questions, how long have you been having those symptoms?

 

____Less than 4 weeks  ____4-12 weeks (1-3 months)  ____Longer than 12 weeks (3 months)

 

PRINT THIS FORM AND FILL IT OUT, BRING IT TO THE CLINIC WITH YOU

Sinus symptom questionnaire