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New Patient Sinus Survey

The following questions is intended to help define your symptoms and provide valuable information and insights for your doctor. Answer the questions, rating to the best of your ability problems you have experienced over the past two weeks.

Sino-Nasal Outcome Test (SNOT-20)

1. Consider 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 ticking the radio button that corresponds with you feel.

2. Please mark the most important items affecting your health (maximum of 5 items).
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
    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
  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
    11. Difficulty falling asleep
    12. Wake up at night
    13. Lack of sleep
    14. Wake up tired
    15. Fatigue
    16. Reduced productivity
    17. Reduced concentration
    18. Frustrated / restless / irritable
    19. Sad
    20. Embarrassed
SCORE:   

Score Evaluation Recommended Next Step
0 to 10 No problem to mild problem No actions necessary or symptoms can be treated with OTC medication.
11 to 40 Moderate problem An appointment with a specialist or your PCP is recommended and/or prescription medicine can be taken to treat symptoms.
41 to 69 Moderate to severe An appointment with a specialist or your PCP is recommended and/or prescription medicine can be taken to treat symptoms.
70 to 100 Severe to “as bad as it can be” And appointment with a specialist is recommended, treatment to be determined by doctor. Possible surgical candidate.
*The SNOT score evaluation is to be used as a guide and not a physician’s diagnosis. Treatment to be determined by doctor upon appointment.





 
 
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