This is a 20 question survey for patients to fill out for any nose or sinus issues.

Please answer these questions twice. Once Before and once After any procedure.

Please rate the severity of your condition on each of the 20 items using a 0-5 category rating system: On a scale of 0-5, rate your symptoms.

0 = No Problem
1 = Very Mild Problem
2 = Mild or Slight Problem
3 = Moderate Problem
4 = Severe Problem
5 = As Bad As It Can Be

[WATUPRO 1]

Score

Evaluation

Recommended Next Step

0 to 10

 No problem to mild problem No actions necessary or symptoms can be treated with OTC medication.

11 to 40

 Moderate problem An appointment with a sinus specialist is recommended and/or prescription medicine can be taken to treat symptoms.

41 to 69

 Moderate to severe An appointment with a specialist is recommended and/or prescription medicine can be taken to treat symptoms. You may benefit from balloon sinuplasty or surgery.

70 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 doctor upon appointment.