Linda Kiser, AuD SNOT-20 (Sinus) Survey

1
Need to blow nose
Problem as bad as it can be
Severe Problem
Moderate Problem
Mild or Slight Problem
Very Mild Problem
No Problem
2
Sneezing
Problem as bad as it can be
Severe Problem
Moderate Problem
Mild or Slight Problem
Very Mild Problem
No Problem
3
Runny nose
Problem as bad as it can be
Severe Problem
Moderate Problem
Mild or Slight Problem
Very Mild Problem
No Problem
4
Cough
Problem as bad as it can be
Severe Problem
Moderate Problem
Mild or Slight Problem
Very Mild Problem
No Problem
5
Post-nasal discharge
Problem as bad as it can be
Severe Problem
Moderate Problem
Mild or Slight Problem
Very Mild Problem
No Problem
6
Thick nasal discharge
Problem as bad as it can be
Severe Problem
Moderate Problem
Mild or Slight Problem
Very Mild Problem
No Problem
7
Ear fullness
Problem as bad as it can be
Severe Problem
Moderate Problem
Mild or Slight Problem
Very Mild Problem
No Problem
8
Dizziness
Problem as bad as it can be
Severe Problem
Moderate Problem
Mild or Slight Problem
Very Mild Problem
No Problem
9
Ear pain
Problem as bad as it can be
Severe Problem
Moderate Problem
Mild or Slight Problem
Very Mild Problem
No Problem
10
Facial pain / pressure
Problem as bad as it can be
Severe Problem
Moderate Problem
Mild or Slight Problem
Very Mild Problem
No Problem
11
Difficulty falling asleep
Problem as bad as it can be
Severe Problem
Moderate Problem
Mild or Slight Problem
Very Mild Problem
No Problem
12
Wake up at night
Problem as bad as it can be
Severe Problem
Moderate Problem
Mild or Slight Problem
Very Mild Problem
No Problem
13
Lack of sleep
Problem as bad as it can be
Severe Problem
Moderate Problem
Mild or Slight Problem
Very Mild Problem
No Problem
14
Wake up tired
Problem as bad as it can be
Severe Problem
Moderate Problem
Mild or Slight Problem
Very Mild Problem
No Problem
15
Fatigue
Problem as bad as it can be
Severe Problem
Moderate Problem
Mild or Slight Problem
Very Mild Problem
No Problem
16
Reduced productivity
Problem as bad as it can be
Severe Problem
Moderate Problem
Mild or Slight Problem
Very Mild Problem
No Problem
17
Reduced concentration
Problem as bad as it can be
Severe Problem
Moderate Problem
Mild or Slight Problem
Very Mild Problem
No Problem
18
Frustrated / restless / irritable
Problem as bad as it can be
Severe Problem
Moderate Problem
Mild or Slight Problem
Very Mild Problem
No Problem
19
Sad
Problem as bad as it can be
Severe Problem
Moderate Problem
Mild or Slight Problem
Very Mild Problem
No Problem
20
Embarrassed
Problem as bad as it can be
Severe Problem
Moderate Problem
Mild or Slight Problem
Very Mild Problem
No Problem
21
Calculation
22
Name
First Name
Last Name
23
Email
example@example.com
24
What can we help you with?
New hearing aids / technology / evaluation
New hearing aids / technology / evaluation
Hearing aid less than three years old - adjust / clean / repair
Hearing aid more than three years old - adjust / clean / repair
Hearing protection - musician / hunting / industrial
Hearing test / evaluation
Ringing in my ear / tinnitus or dizziness
General information about hearing loss / hearing aids
Other
25
Severe to “as bad as it can be”: An appointment with a specialist is recommended, treatment to be determined by the doctor.
26
Moderate to severe: An appointment with a specialist or your Primary Care Physician is recommended and/or prescription medicine can be taken to treat symptoms.
27
No problem to mild problem: You are not experiencing common signs of sinus issues. However, if you are experiencing other symptoms not listed here, please contact our office for a consultation.
Should be Empty: