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Microsoft word - nasal or sinus problems.doc
Nasal or Sinus Problems
INSTRUCTIONS: Please answer all of the questions to the best of your ability before you come to your appointment. All responses will be kept strictly confidential. 1. What is the reason for your scheduled visit? __________________________________________________________________________________________________________________________________________________________ 2. Are you having pain related to this visit? Yes No a) Location of pain:______________________________________________________________ b) Describe the pain:_____________________________________________________________ c) What makes it better?__________________________________________________________ d) What make it worse?__________________________________________________________ e) How long does the pain last?____________________________________________________ 3. Please rate the following symptoms on a severity scale of 0 (absent) to 4 (severe): Recurrent
4. Do you have hay fever or other allergy symptoms?
Have you ever been tested for allergies? Y N When? ________________ If yes, please check your allergies: ____Dust Mite ____Cock Roach ____Mold ____Ragweed ____Grass ____Tree ____Food Did you receive allergy shots? __________ If yes, how long?_________ Did they help? ______ 5. Please rate the effectiveness of any of the following treatments that you have received (1=worst, 4= best): Antibiotics
6. Do you have RECURRENT INFECTIONS? Y N If so, please answer the following questions: a. To the best of your recollection, please list all the antibiotics you have taken for sinus infections, and circle the ones that have been most effective: _____________________________________________________________________________ _____________________________________________________________________________ b. The longest period of time that you have been on a single antibiotic is: ____2 weeks or less ____2-4 weeks ____4 - 8 weeks ____More than 8 weeks 7. Do you have NASAL CONGESTION? Y N
If so, please answer the following question: Which side is more affected? Right Left Both equally 8. Do you have FACIAL PAIN OR PRESSURE? Y
If so,please answer the following questions: a. On which side is your discomfort more prominent? R L Both b. Where is your discomfort most severe? (Check all that apply) ______At the inner angle of the eye ______In the cheeks ______Around or behind the eye ________In the back of the head ______In the temple __________________On the forehead or brow ______Other (please describe): ___________________________________________________ c. Has another physician ever diagnosed you with migraines?
If so, how often do you get migraines? ______________________________________________ Can you distinguish your migraine headache from your sinus pain?
9. Do you have NASAL DISCHARGE or POST-NASAL DRIP? Y
If so, please check all that best describe the typical appearance of your drainage: ____clear _____opaque white ____thin ______thick ____yellow ____blood-tinged _____green ____other 10. Have you had any sinus imaging done?
If so, check which type and list where and when it was done: ____X-Ray ____________________________________________________________________ ____CT ____________________________________________________________________ ____MRI ____________________________________________________________________
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