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A pioneer in sinus relief
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Sinus History
General Information
Name
DOB:
Date
04/25/2024
Complaint
Headaches
Pain/Pressure
Breathing
Sinus Infections
When did symptoms start initially?
Teen
Adult
Other
Since
Sleep Disturbance
No Problem
Snoring
Apnea
Energy Level
Normal
Low
Do you have symptoms?
Intermittently
Daily
Capacity
Do you think your symptoms are
Progressive
Stable
Affecting quality of life
Are your sinus/nose problems something you worry about everyday?
Yes
No
Do you miss work/school
Yes
No
Days missed per year
Dizziness
Yes
No
Please describe
Do you use?
Over the counter sprays
Over the counter Antihistamines
Cortisone Spray
Non-sedative Antihistamines
Saline Irrigations
Allergies
Have you had allergy testing done before?
Yes
No
Have you had allergy shots?
Yes
No
How Long?
Did the shots help?
Do you think you have
Allergies
Asthma
Eczema
Hives
Migraine
Headaches/Facial Pain
How many days per month?
How many hours does the headache last?
Worse in the
Morning
Afternoon
Evening
Constant
Severity
Mild
Moderate
Severe
Quality
Dull
Sharp
Throbbing
Location
Above eyes
Below eyes
Behind eyes
Between eyes
Top of head
Over cheeks
Associated symptoms
Nausea
Tearing
Eye symptoms
Do your symptoms worsen with exposure to
Pressure Change
Cigarette Smoke
Perfumes
Cleaning Product
Other
Does it get worse when you lie down?
Yes
No
Do you have difficulty clearing your throat in the morning?
Yes
No
Which side is affected?
Left
Right
Both sides
Alternating sides
Mouth Breathing
Always
Sometimes
Never
At night
Do you have problems with
Smell
Bad Breath
Sore Throat
Taste
Throat Clearing
Hoarseness
Cough
Aching Teeth
Sinusitis
Number of antibiotic therapies last year?
Last Antibiotic therapy (M/Y)
Relief from Antibiotics
A lot
Somewhat
Not much
Side effects from Antibiotics
None
Stomach Problem
Vaginitis
Post-Nasal discharge/Running Nose
How much
A lot
Not much
Never
Color
Green
Yellow
White
Clear
Medications
Medication Allergies
Have you had?
Sinus X-Ray
Yes
No
X-Ray Results
Normal
Abnormal
CT scans
Yes
No
CT Results
Normal
Abnormal
Septal surgery
Yes
No
When did you have Septal surgery?
Relief from Septal surgery
Lot
Little
None
Sinus surgery
Yes
No
When did you have Sinus surgery?
Relief from Sinus surgery
Lot
Little
None
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