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Call Us Now

(806) 355-9355

Allergy Quiz

Below you will find a list of symptoms and social / emotional consequences of your rhinosinusitis. We would like to know more about these problems. Please answer the following questions to the best of your ability.

1. Do you have nasal / sinus problems?

Yes No

2. Do you have nasal obstruction / blockage / congestion?

Yes No

3. Do you use nasal sprays?

Yes, Currently Yes, In the past Never

4. If Yes, Which spray?

Saline (i.e. Ocean Spray) Steroid (i.e. Flonase, Nasonex) Decongestant (i.e. Afrin)

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

6. Have you had a recent CT scan or MRI for the sinuses?

Yes No

9. Have you ever been tested for allergies?

Yes No

10. Have you ever had allergy shots (allergy immunotherapy)? Yes, for how long? When did you stop?

Considering how severe the problem is and how frequently it happens, rate each item the number that corresponds with how you feel using this scale > > >

ANSWER KEY:

0 = No Problem

1 = Very Mild Problem

2 = Mild/Slight Problem

3 = Moderate Problem

4 = Severe Problem

5 = Problem as Bad as it Can Be

Select the correct answer for you.

0 1 2 3 4 5
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/Pressure
10. Facial Pain/Pressure
11. Difficulty Falling Asleep
0 1 2 3 4 5
12. Wake Up at Night
13. Lack of a Good Night's Sleep
14. Wake Up Tired
15. Fatigue During the Day
16. Reduced Productivity
17. Reduced Concentration
18. Frustrated/Restless/Irritable
19. Sad
20. Embarrassed
21. Sense of Smell/Taste
22. Congestion/Obstruction of Nose

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