Skip to content
Search for:
Home
About
Specialties
The Ear
The Nose
The Throat
Outpatient Surgery
Resources
Contact Us
Testimonials
Post-Op Instructional Videos
Search for:
CRS Survey
Home
/
Patient Forms
/
CRS Survey
CRS Survey
aurshax
2019-01-04T17:55:17+00:00
CRS Survey
Step 1 of 2
50%
Name
*
First
Last
Today's Date
*
Date Format: MM slash DD slash YYYY
Have you had a sinus infection in the past year?
*
Yes
No
How many?
0 to 1
2 to 4
> 5
Have you taken an antibiotic in the last year?
*
Yes
No
What kind?
How many times?
0 to 1
2 to 4
> 5
Do you have sinus headaches (not migraine)?
*
Yes
No
How many times?
0 to 1
2 to 4
> 5
Per
Week
Month
Year
Worse on
Right
Left
Both Sides
Cheeks
Back of Head
Have you had aspirin allergy?
*
Yes
No
Do you have loss of smell?
*
Yes
No
Do you have nasal airway obstruction?
*
Yes
No
Grade from 0 to 4: (0 = no blockage; 4 = completely blocked on 1 or both sides)
0
1
2
3
4
Do you have postnasal drip?
*
Yes
No
Grade from 0 to 4: (4 = most)
0
1
2
3
4
Do you have any allergies?
*
Yes
No
What kind of allergies?
Have you been tested for allergies?
Yes
No
Have you ever taken allergy shots?
Yes
No
When did you take allergy shots?
How long did you take allergy shots?
Have you had drainage from the nose?
Yes
No
Have you had sinus surgery?
Yes
No
How many sinus surgeries have you had?
Date of the last surgery
Date Format: MM slash DD slash YYYY
Do you smoke?
Yes
No
Environmental History:
Has the furnace or air conditioner location in your home ever been damp?
*
Yes
No
Is the heater or air conditioner located in a dirt crawl space?
*
Yes
No
Is the crawl space damp?
*
Yes
No
Is the heater located in the attic with blown-in insulation?
*
Yes
No
Do you have a humidifier in the central furnace?
*
Yes
No
Have you ever had a leak or flood anywhere in your home?
*
Yes
No
Do you ever notice a musty smell in the house?
*
Yes
No
Have you ever noticed any mold in the house (other than the bathroom)?
*
Yes
No
Do you or co-workers feel bad at the office?
*
Yes
No
Do you feel better away from home or away from the office?
*
Yes
No
Do you have pets in the home?
*
Yes
No
What kind of pet?
Do your pets sleep with you?
*
Yes
No
Do you have a front loader washer?
*
Yes
No
Has your car ever been wet/leaked on the inside?
*
Yes
No
Do you drive a BMW?
*
Yes
No
A. Sinus and upper respiratory symptoms:
1. Asthma
*
Yes
No
2. Bronchitis
*
Yes
No
B. General symptoms:
1. Fatigue grade 0-10 0=can’t get out of bed 10=can walk 5 miles
*
0
1
2
3
4
5
6
7
8
9
10
2. Abdominal pain
*
Yes
No
3. Allergic complex to foods
*
Yes
No
4. Attention Deficit Disorder (ADD)
*
Yes
No
5. Constipation
*
Yes
No
6. Diabetes
*
Yes
No
7. Diarrhea
*
Yes
No
8. Bloating and/or gas
*
Yes
No
9. Stomach Pain
*
Yes
No
10. Gut Problems ( Enteropathy)
*
Yes
No
11. Leakey Gut Syndrome
*
Yes
No
12. Gluten Sensitivity
*
Yes
No
13.Loss of protein in gut
*
Yes
No
14.Gastritis (Stomach inflammation)
*
Yes
No
15. Cloitis (bowel inflammation)
*
Yes
No
16. Hyperactivity
*
Yes
No
17. Hypoglycemia (low blood sugar)
*
Yes
No
18. Interstitial cystitis (bladder inflammation)
*
Yes
No
19. Migraine
*
Yes
No
20. Obesity
*
Yes
No
21. Muscle and/or joint pain/fibromyalgia
*
Yes
No
22. Weakness
*
Yes
No
23. Memory loss and/or problems concentrating
*
Yes
No
24. Irritable bowel syndrome
*
Yes
No
25. Blurred vision
*
Yes
No
26. Chest tightness
*
Yes
No
27. Insomnia
*
Yes
No
28. Numbness / tingling
*
Yes
No
29. Laryngitis
*
Yes
No
30. Anxiety, depression, or irritability?
*
Yes
No
31. Skin rashes
*
Yes
No
32. Psoriasis
*
Yes
No
33. Eczema
*
Yes
No
34. Hives
*
Yes
No
35. Urticaria (itching)
*
Yes
No
36. Tremors/seizures
*
Yes
No
37. Shortness of breath
*
Yes
No
38. Cancer
*
Yes
No
39. Lymphoma
*
Yes
No
40. Leukemia
*
Yes
No
41. Lupus
*
Yes
No
42. Esophageal acid reflux
*
Yes
No
C. Female Disorder Symptoms (Please answer only if you feel comfortable giving this information):
1. Infertility
Yes
No
Did you ever have a normal pregnancy?
Yes
No
2. Polycystic ovary
Yes
No
3. Endometriosis
Yes
No
4. Tubal blockage
Yes
No
5. Hormonal or ovulation difficulty
Yes
No
Email
This field is for validation purposes and should be left unchanged.
Page load link
Go to Top
