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Sinusitis Questionnaire

Rate each item below based on the severity and frequency of your symptoms. No Problem Very Mild Problem Mild or Slight Problem Moderate Problem Severe Problem Problem as bad as it can be
0 1 2 3 4 5
1. Need to blow nose
2. Sneezing
3. Runny Nose
4. Nasal Obstruction
5. Loss of smell or taste
6. Cough
7. Post-nasal Discharge
8. Thick Nasal Discharge
9. Ear Fullness
10. Dizziness
11. Ear Pain
12. Facial Pain/Pressure
13. Difficulty falling asleep
14. Waking up at night
15. Lack of a good night’s sleep
16. Waking up tired
17. Fatigue
18. Reduced Productivity
19. Reduced Concentration
20. Frustrated/Restless/Irritable
21. Sadness
22. Embarrassed
Total Score

Score Explanation

Score Evaluation Recommended Next Step
0 to 9 Mild Problem Symptoms can generally be treated with over-the-counter medications and/or allergy therapy.
10-29 Moderate Problem Appointment with specialist recommended.  May require allergy immunotherapy and/or prescription medications for optimal relief.  Less likely to require surgical procedure.
30-49 Moderately Severe Problem Appointment with specialist recommended.  Higher likelihood that a surgical procedure will be required for optimal relief.
50+ Severe Problem Appointment with specialist recommended.  Very likely to require surgical procedure for optimal relief.

This scoring system applies primarily to inflammatory conditions such as allergy-related sinus disease. There are some sinus conditions that require surgery regardless of whether or not they cause significant symptoms. For example, sinus mucoceles and fungal sinusitis may persist with relatively few symptoms for a long time; however, if not properly managed, these patients may be at risk for complications of sinusitis such as vision compromise or infection around the brain. Let a physician decide if a mild or asymptomatic sinus condition can be safely managed with non-surgical treatments alone.

* The evaluation is to be used as a guide and not a physician’s diagnosis. Treatment to be determined by a doctor upon appointment.

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