Ear Nose and Throat Patient Registration Form

Below you will find a list of symptoms and social/emotional consequences of your rhinosinusitis. We would like to know more about these problems and would appreciate your answering the following questions to the best of your ability. There are no right or wrong answers, and only you can provide us with this information. Please rate your problems as they have been over the past two weeks. Thank you for your participation. Do not hesitate to ask for assistance if necessary.

	No Problem	Very Mild	Mild or slight	Moderate	Severe	Problem as bad as it can be	5 Most important items affecting your health I
1. Need to Blow Nose	1	2	3	4	5	6	7
2.Nasal Blockage	8	9	10	11	12	13	14
3. Sneezing	15	16	17	18	19	20	21
4. Runny Nose	22	23	24	25	26	27	28
5. Cough	29	30	31	32	33	34	35
6. Post-Nasal Discharge	36	37	38	39	40	41	42
7. Thick Nasal Discharge	43	44	45	46	47	48	49
8. Ear Fullness	50	51	52	53	54	55	56
9. Dizziness	57	58	59	60	61	62	63
10. Ear Pain	64	65	66	67	68	69	70
11. Facial Pain/Pressure	71	72	73	74	75	76	77
12. Decreased Sense of Smell/Taste	78	79	80	81	82	83	84
13. Difficulty Falling Asleep	85	86	87	88	89	90	91
14. Wake up at night	92	93	94	95	96	97	98
15. Lack of a Good Nights Sleep	99	100	101	102	103	104	105
16. Wake up Tired	106	107	108	109	110	111	112
17. Fatigue	113	114	115	116	117	118	119
18. Reduced Productivity	120	121	122	123	124	125	126
19. Reduced Concentration	127	128	129	130	131	132	133
20.Frustrated/Restless/Irritable	134	135	136	137	138	139	140
21. Sad	141	142	143	144	145	146	147
22. Embarrassed	148	149	150	151	152	153	154

Please upload any previous medical records, including imaging:

A Notice to Our Valued Patients

During your visit in our ENT department, your physician may find it necessary to use endoscopes (special lighted instruments) as part of their evaluation. This will enable your physician to provide you with the most thorough examination of your sinuses and throat when needed. Although, this is fairly routine for our specialty, most insurance companies consider this a "surgery" or "in-office procedure" and it may be reflected as such on your billing statement or explantion of benefits. In addition, your physician may also require you to have an Audiogram, also known as a hearing test. Each of these services will result in an additional charge and therefore an additional financial responsibility for you. We want you to be informed of these services so there are no surprises or concerns after you leave our office.

Please sign below to acknowledge that you received the office notification regarding office Endoscopies/Audiograms and are aware that it may be performed during your visit.

Ear Nose and Throat Patient Registration Form

SINO-NASAL OUTCOME TEST