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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