Considering how severe the problem is when you experience it and how often it happens, please rate each item below on how “bad” it is by circling the number that corresponds with how you feel using this scale

No
problem

Very mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

0

1

2

3

4

5

Name(Required)
1. Need to blow nose
2. Nasal blockage
3. Sneezing
4. Runny nose
5. Cough
6. Post-nasal discharge
7. Thick nasal discharge
8. Ear fullness
9. Dizziness
10. Ear pain
11. Facial pressure/pain
12. Decreased sense of smell/taste
13. Difficulty falling asleep
14. Wake up at night
15. Lack of a good night’s sleep
16. Wake up tired
17. Fatigue
18. Reduced productivity
19. Reduced concentration
20. Frustrated, restless, irritable
21. Sad
22. Embarrassed
This field is for validation purposes and should be left unchanged.

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