Quick Self-Assessment for Sinusitis

1
Your Name* This field is required.
First Name
Last Name
2
Your Email* This field is required.
example@example.com
3
Your Phone no.* This field is required.
4
Q1. I have persistent facial pressure and pain.* This field is required.(lasting 10+ days)
YESNO
5
Q2. I have on-going congestion or stuffy nose.* This field is required.(lasting 10+ days)
YESNO
6
Q3. I have headache.* This field is required.(lasting 10+ days)
YESNO
7
Q4. I get pain in my upper teeth.* This field is required.(lasting 10+ days)
YESNO
8
Q5. I have low-grade fevers (37.3 - 37.8°C)* This field is required.(lasting 10+ days)
YESNO
9
Q6. I suffer from bad breath that doesn’t go away.* This field is required.(lasting 10+ days)
YESNO
10
Q7. I have thick, yellow-green nasal discharge.* This field is required.(lasting 10+ days)
YESNO
11
Q8. I have experienced these symptoms for 12 or more consecutive weeks.* This field is required.
YESNO
12
Q9. I have had these symptoms for 10+ days four or more times in the last 12 months.* This field is required.(with periods of no symptoms)
YESNO
13
Q10. I’ve tried medication treatments and home remedies without success.* This field is required.
YESNO
14
Calculation
15
How likely would you go for medical treatment to help to relieve your symptoms?
Unlikely
Somewhat Likely
Most Likely
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Unlikely
Row 0, Column 0
Somewhat Likely
Row 0, Column 1
Most Likely
Row 0, Column 2
16
Hit "Submit" to see your results in the next page!

*In submitting this form I agree to my details being used by Easmed for the purposes of data collection and I consent to receive emails from Easmed. The information will only be accessed by Easmed and their partners. I understand my data will be held securely and will not be distributed to third parties outside of Easmed's partners. I have a right to change or access my information. I understand that I can unsubscribe from the mailing list anytime after submission.
Should be Empty: