Total Nasal Symptom Score Test for RhinAer® Treatment
How would you rate your nasal congestion symptoms?
*
0 - No symptoms
1 - Mild symptoms present but easily tolerated
2 - Moderate symptoms present and bothersome
3 - Severe symptoms present and interfere with activities of daily living and/or sleep
How would you rate your runny nose symptoms?
*
0 - No symptoms
1 - Mild symptoms present but easily tolerated
2 - Moderate symptoms present and bothersome
3 - Severe symptoms present and interfere with activities of daily living and/or sleep
How would you rate your nasal and throat itching symptoms?
*
0 - No symptoms
1 - Mild symptoms present but easily tolerated
2 - Moderate symptoms present and bothersome
3 - Severe symptoms present and interfere with activities of daily living and/or sleep
How would you rate your sneezing symptoms?
*
0 - No symptoms
1 - Mild symptoms present but easily tolerated
2 - Moderate symptoms present and bothersome
3 - Severe symptoms present and interfere with activities of daily living and/or sleep
Total Score
*
Add together numbers from above questions and enter here.
Click next to share your results with a QMG Ear, Nose, and Throat (ENT) specialist.
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Share Your Results
Send your Total Nasal Symptom Score to QMG's Ear, Nose, and Throat specialists and find out if you are a candidate for the RhinAer® procedure. Please complete the following information and we will be in touch.
Your Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Have you seen a Quincy Medical Group Ear, Nose, and Throat provider in the past?
*
Yes
No
If yes, when were you last seen? (If you are unsure of the exact date, an estimate is fine)
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Preferred Method of Contact
*
Telephone
MyChart Message
If we need to reach out to you via telephone during business hours (M-F, 8:00 am - 5:00 pm), do you have a preferred time/day of the week we can call you?
*
Do you have any questions or comments you would like to share with us?
Submit
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