Sinus Questionnaire
The following questionnaire is intended to help define your symptoms and provide valuable information and insights for your doctor. Answer the following questions with "yes" or "no" if you have experienced each issue or not. Your information will remain confidential and may be used with any upcoming appointments you may have with our doctor.
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Email *
What is your first and last name? *
What is your date of birth? *
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What is a good contact number for you? *
Do you often have the need to blow your nose?
Clear selection
Do you experience nasal blockage and/or congestion?
Clear selection
Do you sneeze often or feel like you have allergies?
Clear selection
Do you have or have experienced a runny nose within the last two weeks?
Clear selection
Do you experience coughing?
Clear selection
Do you have post-nasal drip (mucus/phlegm in throat) or constantly have to clear your throat?
Clear selection
Do you have thick nasal discharge?
Clear selection
Are you a mouth breather?
Clear selection
Do you have or have had sinus infections?
Clear selection
Do you have or have had an upper respiratory infection?
Clear selection
Do you get facial pain/pressure? Headaches?
Clear selection
Do you have a decreased sense of smell and/or taste?
Clear selection
Do you have difficulty falling asleep?
Clear selection
Do you wake up at night coughing/choking?
Clear selection
Do you lack a good night's sleep?
Clear selection
Do you wake up tired?
Clear selection
Do you experience fatigue?
Clear selection
Do you experience reduced productivity with your day to day?
Clear selection
Do you have reduced concentration?
Clear selection
Do you often feel frustrated, restless, and/or irritable?
Clear selection
Do you snore?
Clear selection
Have you had an allergy test?
Clear selection
If you said yes, what were the results of the allergy test?
A copy of your responses will be emailed to the address you provided.
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