Sino-Nasal Outcome Test (SNOT-22)
I.D.
Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Considering how severe the problem is when you experience it and how often it happens, please rate each item below on how "bad" it is by choosing the number that corresponds with how you feel using this scale:
Rows
No Problem (0)
Very Mild Problem (1)
Mild or Slight Problem (2)
Moderate Problem (3)
Severe Problem (4)
Problem as bad as it can be (5)
Need to blow nose
Nasal Blockage
Sneezing
Runny nose
Cough
Post-nasal discharge
Thick nasal discharge
Ear fullness
Dizziness
Ear pain
Facial pain/pressure
Decreased Sense of Smell/Taste
Difficulty falling asleep
Wake up at night
Lack of a good night’s sleep
Wake up tired
Fatigue
Reduced productivity
Reduced concentration
Frustrated/restless/irritable
Sad
Embarrassed
Please mark the most important items affecting your health (maximum of 5 items)
Need to blow nose
Nasal Blockage
Sneezing
Runny nose
Cough
Post-nasal discharge
Thick nasal discharge
Ear fullness
Dizziness
Ear pain
Facial pain/pressure
Decreased Sense of Smell/Taste
Difficulty falling asleep
Wake up at night
Lack of a good night’s sleep
Wake up tired
Fatigue
Reduced productivity
Reduced concentration
Frustrated/restless/irritable
Sad
Embarrassed
Submit
Should be Empty: