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0407 924 224
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Symtom Evaluation Form

NASAL OBSTRUCTION SYMPTOM EVALUATION (NOSE)

FullName:

Date:

Email:

DOB:

Please help us to understand the impact of the nasal obstruction on your quality of life by completing the following survey. Over the past 1 month, how much of a problem were the following conditions for your? Please circle the most correct response

Nasal congestion:

NoneMildModerateBadSevere

Nasal blockage or obstruction:

NoneMildModerateBadSevere

Trouble breathing through the nose:

NoneMildModerateBadSevere

Trouble sleeping:

NoneMildModerateBadSevere

Unable to get enough air through the nose during exercise or exertion :

NoneMildModerateBadSevere

Please circle the most correct response

How troublesome is your diﬃculty in breathing through your nose over all?

0123456789

How troublesome is your diﬃculty in breathing for your left nostril?

0123456789

How troublesome is your diﬃculty in breathing for your right nostril?

0123456789

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Septoplasty
Functional Edoscopic Sinus Surgery (FESS)
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