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About SSI
A pioneer in sinus relief
Education that never ends
Teaching the experts
The FIERO award
Acclaimed publications
Sinus Breakthroughs
The power behind an idea
Small holes can solve big problems
Preserve much, invade little
A deeper Look at anatomy
Sinus Education
Getting to know your sinuses
Sinus terminology & definitions
How the sinuses work
What causes sinus problems
The definition of a sinus problem
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Health Questionnaire 1
Personal Information
Name
DOB
Date
03/29/2024
Family History
Adopted and don't know family history
If any blood relative has had any of the following, please indicate using the key on the side of the page.
Alchoholism
Anemia or any blood disease
Osteoporosis
Coronary Artery Disease
High Blood Pressure
Depression
Kidney Failure
Emphysema
Asthma
High Cholesterol
Hypothyroid
Heart Disease
Heart Attacks
Congestive Heart Failure
Other diseases of heart
Other Disorders family related
Stroke
Arthritis
Diabetes
Cancer Type
Key
1. Mother
2. Father
3. Daughter
4. Son
5. Sister
6. Brother
7. Aunt
8. Uncle
9. Maternal Grandfather
10. Maternal Grandmother
11. Paternal Grandfather
12. Paternal Grandmother
13. Other
Patient Medical History
Eyes
Eye Pain
Yes
No
Vision Changes
Yes
No
Excessive Tearing
Yes
No
Itching
Yes
No
Blurring
Yes
No
Skin
Rashes
Yes
No
Itching
Yes
No
Gout
Yes
No
Easy Bruising
Yes
No
Eczema/Psoriasis
Yes
No
Any other skin disorders
Respiratory
Asthma
Yes
No
Cough
Yes
No
Wheezing
Yes
No
Snoring
Yes
No
Sleep Apnea
Yes
No
Emphysema
Yes
No
Heart Burn
Yes
No
Allergic/Immunologic
Hay Fever
Yes
No
Persistent Infections
Yes
No
Reaction To Anesthesia
Yes
No
Explain
General
Anemia
Yes
No
Anxiety
Yes
No
Arthritis
Yes
No
Depression
Yes
No
Osteoporosis
Yes
No
Diabetes
Yes
No
High Blood Pressure
Yes
No
Rheumatic Fever
Yes
No
Prostate Problems
Yes
No
Fevers
Yes
No
Chills
Yes
No
Sweats
Yes
No
Fatigue/Insomnia
Yes
No
Sleep Problems
Yes
No
Weight Gain
Yes
No
Weight Gain Pounds
Weight Loss
Yes
No
Weight Loss Pounds
Child Speech Delay
Yes
No
Cancer
Yes
No
Explain
IBS
Yes
No
High Cholesterol
Yes
No
Kidney Problems
Yes
No
Alcoholism
Yes
No
Jaundice/Hepatitis
Yes
No
Heart Problems
Yes
No
Explain
Ear, Nose, and Throat
Ringing in Ears
Yes
No
Ear Fullness/Pressure
Yes
No
Hearing Loss (RT or LT)
Yes
No
Dizziness/Spinning
Yes
No
Nasal Congestion
Yes
No
Post Nasal Drainage
Yes
No
Nose Bleeds
Yes
No
Runny Nose
Yes
No
Decreased Sense of Smell
Yes
No
Decreased Sense of Taste
Yes
No
Sore Throats
Yes
No
Frequent Throat Clearing
Yes
No
Change In Voice
Yes
No
Hoarseness
Yes
No
Bad Breath
Yes
No
History of Nasal Polyps
Yes
No
Thyroid Issues
Yes
No
Explain
Neuro
Headaches
Yes
No
Syncope
Yes
No
Facial Pain/ Pressure
Yes
No
Stroke
Yes
No
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