Online Sinus Questionnaire

Below you will find a list of symptoms and social/emotional consequences typically associated with sinus issues.  There are no right or wrong answers, so make sure to provide the most honest answers for yourself. Please rate your problems, as they have been over the past two weeks.

Thank you for taking the time to visit www.sinusreliefny.com and please contact us at 845-360-9197 with any questions you may have.

Considering how severe the problem is when you experience it and how frequently it happens, please rate each item below on how ‘bad’ it is by selecting the number that corresponds with how you feel using this scale:
SNOT-20

1. Need to blow nose

 
 
 
 
 
 

2. Sneezing

 
 
 
 
 
 

3. Runny nose

 
 
 
 
 
 

4. Cough

 
 
 
 
 
 

5. Post nasal discharge

 
 
 
 
 
 

6. Thick nasal discharge

 
 
 
 
 
 

7. Ear fullness

 
 
 
 
 
 

8. Dizziness

 
 
 
 
 
 

9. Ear pain

 
 
 
 
 
 

10. Facial pain/pressure

 
 
 
 
 
 

11. Difficulty falling asleep

 
 
 
 
 
 

12. Wake up at night

 
 
 
 
 
 

13. Lack of a good night’s sleep

 
 
 
 
 
 

14. Wake up tired

 
 
 
 
 
 

15. Fatigue

 
 
 
 
 
 

16. Reduced productivity

 
 
 
 
 
 

17. Reduced concentration

 
 
 
 
 
 

18. Frustrated/restless/irritable

 
 
 
 
 
 

19. Sad

 
 
 
 
 
 

20. Embarrassed