Snot 22

SNOT 22

This questionnaire is designed to help determine your symptoms and provide your doctor with valuable information about your sinus disease. Please answer the questions, rating to the best of your ability the problems you have experienced over the past two weeks. Consider how severe the problem is when you experience it and how frequently it happens, please rate each question on how "bad" it is by selecting the number that corresponds with how you feel.

*The higher you score means your sinus problems are more severe

Question Title

* 1. First and Last name:

Question Title

* 2. Please provide us with your email address to allow provider to contact you to discuss whether you're a candidate or not.

Question Title

* 3. Phone number:

Question Title

* 4. Gender

Question Title

* 5. Age

Question Title

* 6. Which office location do you prefer?

Question Title

* 7. How did you hear about us?

Google Search

Friend/Family

Primary Care Physician

Yelp

Insurance

Zoc Doc

Real Self

Yellow Pages

Dentist

Other (please specify)

For the following questions, please answer based on how your symptoms have been, if it is not a problem for you, select "no problem". Your score will be based on how severe each problem is that you are experiencing. The more severe results in a higher score.

Question Title

* 8. Need to blow nose

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem

Question Title

* 9. Cough

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem

Question Title

* 10. Sneezing

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem

Question Title

* 11. Runny nose

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem

Question Title

* 12. Post nasal discharge

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem

Question Title

* 13. Thick nasal discharge

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem

Question Title

* 14. Ear fullness

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem

Question Title

* 15. Ear pain

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem

Question Title

* 16. Dizziness

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem

Question Title

* 17. Facial pain/Pressure

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem

Question Title

* 18. Difficulty falling asleep

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem

Question Title

* 19. Lack of sleep

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem

Question Title

* 20. Wake up at night

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem

Question Title

* 21. Wake up tired

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem

Question Title

* 22. Fatigue

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem

Question Title

* 23. Reduced productivity

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem

Question Title

* 24. Reduced concentration

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem

Question Title

* 25. Frustrated/Restless/Irritable

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem

Question Title

* 26. Sad

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem

Question Title

* 27. Embarrassed

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem

Question Title

* 28. Sense of taste/smell

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem

Question Title

* 29. Blockage/Congestion of nose

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

No problem