Stanford Sinus Center New Patient Questionnaire
STANFORD SINUS CENTER NEW PATIENT QUESTIONNAIRE
801 Welch Rd., Stanford, CA 94305
INSTRUCTIONS: Please answer all of the questions to the best of your ability before you come to your appointment. All responses will be kept strictly confidential.
1. What is the reason for your appointment?
__________________________________________________________
What problem is bothering you the most?
__________________________________________________________
How long has it been bothering you?
__________________________________________________________
Who are you referred by?
________Self ______Doctor Name___________________________
2. Do you have FACIAL PAIN OR PRESSURE? Y N
If so, please answer the following questions:
a. On which side is your discomfort more prominent? R L Both
b. How severe is it? Mild Moderate Severe
c. Where do you have discomfort? (Check all that apply)
______ Between the eyes
______ Cheeks
______ Around/behind the eye
______ Back of the head
______ Temple
______ Forehead
______ Other: ___________________
d. Has a physician ever diagnosed you with migraines? Y N
e. Can you distinguish your migraines from your sinus pain? Y N
3. Do you have NASAL CONGESTION or BLOCKED BREATHING? Y N
If so, which side is more affected? Right Left Both equally
4. Do you have NASAL DISCHARGE or POST-NASAL DRIP? Y N
How would you describe it? Clear Discolored Bloody
5. How is your SENSE OF SMELL? Normal Diminished Absent
6. Check all of the following symptoms that apply to you:
______ Headache
______ Fever
______ Bad breath
______ Fatigue
______ Dental pain
______ Cough
______Ear pressure
______ Nosebleeds
7. Do you have hay fever or other allergy symptoms? Y N
Have you ever been tested for allergies? Y N When? _______________________
If yes, please list your allergies:________________________________________
Did you receive allergy shots? __________ If yes, how long?_________ Did they help? ______
8. Do you have RECURRENT INFECTIONS? Y N
If so, please list all the antibiotics you have taken for sinus
infections:______________________________________________________________________________________________________________________________________________________________________________________
The longest period of time that you have been on a single antibiotic is:
................
................
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