SINUSITIS QUESTIONNAIRE

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Please correct the errors described below.

Name

Date

Please tell us more about your sinuses. Fill this form out to the best of your knowledge, and this will help with your diagnosis and treatment planning

When was your first sinus infection (sinusitis)?

1 week ago 1 month ago 6 months ago 1 year ago 5 years ago More than 5 years ago

What are your biggest symptoms (problems) when you have a sinus infection? Please mark ALL that apply:

Facial pain

Post nasal drip (mucus runs down throat)

Foul odor/ taste

Loss of smell

Stuffiness

Other:

If other, please specify:

Which antibiotics have you had in the last 6 months? (Mark ALL that apply):

Amoxicillin

Azithromycin (Zithromax)

Clarithromycin (Biaxin)

Ceftin (cefuroxime)

Vantin (cefpodoxime)

Augmentin®

Cleocin (clindamycin)

Ciprofloxacin (Cipro)

Vibramycin (tetracycline)

Erythromycin

Sulftsoxisole/Trimethoprim (Septra, Bactrim)

Other:

If other, please specify:

What other treatments have you tried? (Mark ALL that apply):

Saline rinse

Guaifenisin (Mucinex)

SSKI

Nasal Steroids (Flonase / Nasonax Omnaris / Nasalide / Vancenase

Has there been any periods of relief during this illness?

Yes No

If yes, how long?

1week 1month 6months 1year 5years

Have you had a CAT Scan of your sinuses?

Yes No

If yes, where and when?

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