SINO-NASAL OUTCOME TEST

The following questionnaire is intended to help define your symptoms and provide valuable information and insight for your doctor.  Answer the questions, rating to the best of your ability the problems you have experienced over the past two weeks.

1. Consider how severe the problem is when you experience it and how frequently it happens.  Please rate each item on how "bad" it is by
    choosing the number from the drop down list.
2. In addition to completing/rating your symptoms on the SNOT Questionnaire, please place an x beside the five (5) most severe symptoms.

Patient Name: Date:
Email Address: Phone Number:
How did you find us? We want to know.
Internet Newspaper Press Release Newsletter Word of Mouth TV Ad 
Primary Care Physician Who?  Other
 
  Description Please choose a score from the drop down list below  Check up to 5 of your
most severe symptoms.
 Need to blow nose
 Sneezing
 Runny nose
 Cough
 Post-nasal discharge
  Thick nasal discharge
 Ear fullness
 Dizziness
 Ear pain
 Facial pain / pressure
 Difficulty falling asleep
 Wake up at night
 Lack of sleep
 Wake up tired
 Fatigue
 Reduced productivity
 Reduced concentration
 Frustrated / restless / irritable
 Sad
 Embarrassed

 

TOTAL SCORE

Score Evaluation Recommended Next Step
0 to 39 No problem to mild problem No action necessary or symptoms can be treated with OTC medication
40 to 59 Mild to moderate problem Symptoms can most likely be treated with OTC medication or prescription medicine
60 to 79 Moderate to severe An appointment with a specialist or your PCP is recommended and/or
prescription medicine can be taken to treat symptoms
80 to 100 Severe to "as bad as it can be" An appointment with a specialist is recommended, treatment to be determined by doctor. Possible surgical candidate.
*The SNOT score evaluation is to be used as a guide and not a physician's diagnosis. Treatment to be determined by a doctor upon appointment.

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