Ear, Nose & Throat

Charles F. Lano, Jr., MD Board Certified in Otolaryngology and Sleep Medicine Fellow in Otolaryngic Allergy

Sinus/Allergy/Congestion/Sleep Apnea/Ear Complaints Questionnaire

Dawn Schuster, MSN, APRN, FNP-C Nurse Practitioner

Do you suffer from Allergy Symptoms? (Circle all the apply)

Heather Schwirtlich, MSN, APRN, FNP-C Nurse Practitioner

Post Nasal Drip (Drainage to Throat)

Amanda Scarbrough, Au.D., CCC-A Clinical Audiologist

Do you experience Headaches? Do you experience: Sinus Pressure/Pain? (Pressure or Pain to the Face) Thick Nasal Discharge? Runny Nose? Nasal Congestion? (Stuffy Nose) Are you a Mouth Breather? Do you snore? Do you feel like you sleep well at night? Are you tired when you wake up? Diagnosed with Sleep Apnea? Do you have trouble with smell? Do you have trouble with taste? Do you have trouble with bad breath? Do you have ear complaints? (Circle all the apply)

YES YES YES YES YES YES YES YES YES YES YES

NO NO NO NO NO NO NO NO NO NO NO

Have you had sinus surgery in the past? If yes, what year? How many years have you suffered with sinus problems? How many times a year do you suffer with sinus symptoms? What medications are you currently on or taken in the past? (Circle all the apply)

Steroid InjectionsOral Steroids

Which antibiotics (if any) have you been on for sinus infections?