Sinus Quiz

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 10	No Problem	No actions necessary or symptoms can be treated with off-the-counter medication.
11 to 40	Moderate Problem	An appointment with a specialist is recommended and/or prescription medicine can be taken to treat symptoms.
41 to 69	Moderate to severe	An appointment with a specialist is recommended to determine the best treatment options.
70 to 100	Severe to “as bad as it can be”	An appointment with a specialist is recommended, treatment to be determined by doctor. Possible surgical candidate.

* 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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