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
- 0
- 1
- 2
- 3
- 4
- 5
2. Sneezing
- 0
- 1
- 2
- 3
- 4
- 5
3. Runny Nose
- 0
- 1
- 2
- 3
- 4
- 5
4. Nasal Obstruction
- 0
- 1
- 2
- 3
- 4
- 5
5. Loss of smell or taste
- 0
- 1
- 2
- 3
- 4
- 5
6. Cough
- 0
- 1
- 2
- 3
- 4
- 5
7. Post-nasal Discharge
- 0
- 1
- 2
- 3
- 4
- 5
8. Thick Nasal Discharge
- 0
- 1
- 2
- 3
- 4
- 5
9. Ear Fullness
- 0
- 1
- 2
- 3
- 4
- 5
10. Dizziness
- 0
- 1
- 2
- 3
- 4
- 5
11. Ear Pain
- 0
- 1
- 2
- 3
- 4
- 5
12. Facial Pain/Pressure
- 0
- 1
- 2
- 3
- 4
- 5
13. Difficulty falling asleep
- 0
- 1
- 2
- 3
- 4
- 5
14. Waking up at night
- 0
- 1
- 2
- 3
- 4
- 5
15. Lack of a good night’s sleep
- 0
- 1
- 2
- 3
- 4
- 5
16. Waking up tired
- 0
- 1
- 2
- 3
- 4
- 5
17. Fatigue
- 0
- 1
- 2
- 3
- 4
- 5
18. Reduced Productivity
- 0
- 1
- 2
- 3
- 4
- 5
19. Reduced Concentration
- 0
- 1
- 2
- 3
- 4
- 5
20. Frustrated/Restless/Irritable
- 0
- 1
- 2
- 3
- 4
- 5
21. Sadness
- 0
- 1
- 2
- 3
- 4
- 5
22. Embarrassed
- 0
- 1
- 2
- 3
- 4
- 5
Total Score
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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

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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