Nasal/Sinus Worksheet

Name:

Date of Birth:

Date:

Do you have nasal obstruction/blockage/congestion:

Yes No

If yes, please specify which side is worse:

Right Left Both

Do you use nasal sprays?

Never Currently In the past

If Currently is selected, please specify the name of spray:

If In the Past is selected, please specify the name of spray:

How many sinus infections have you been treated for in the past year?

Have you had a recent CT or MRI of your head/sinuses?

No Yes

If yes, please specify the date:

If yes, please specify the Location

Please check all symptoms that apply:

Nasal drainage

Decreased sense of smell

Headache

Postnasal drainage

Facial

Sneezing

Itchy eyes or nose

Watery eyes or nose

If Headache is selected, please specify which location:

Facial

Pain Pressure Fullness

Have you ever been tested for allergies?

Yes No

If yes, Result:

Have you ever had allergy shots (allergy immunotherapy)?

Yes No

If yes, for how long?

If yes, please specify date stopped:

Please select the number that best describes your symptoms over the past 2 weeks.

Use this scale to describe how bad the problem when it occurs

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