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.
Back
Next
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.
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
Should be Empty: