SINUS HISTORY
Name:______
Date:______
COMPLAINT: Headaches____Facial Pain/Pressure____Hard Time Breathing ____Sinus Infections____ MEDICATION ALLERGIES:
WHEN DID SYMPTOMS START INITIALLY? Teen ___ Adult ___ Other ___ Since (MO/YR)______
HEADACHES/FACIAL PAIN: How many days per month:____ How many hours does the headache last?______
Worse in the: morning_____afternoon_____ evening______constant pain which gets worse_____
Severity: mild____ moderate____ severe____ Quality: dull____ sharp____ throbbing______
Location: above the eyes____ below the eyes____ behind the eyes____
Between the eyes____ top of head____ over cheeks______
Associated Symptoms: nausea____ tearing____ eye symptoms____
Do your symptoms worsen with expose to: pressure changes____ cigarette smoke____perfumes____
cleaning products____ other______
HARD TIME BREATHING/MOUTH BREATHING: Does it get worse when you lie down? Yes______No______
Which side is affected? Right______Left______Both sides______Alternating sides______
Mouth breathing: Always______Sometimes______Never______At night______
Do you have problems with: Smell______Bad breath______Sore throat______Taste______
Frequent throat clearing______Aching teeth______Hoarseness______Cough______
Do you have difficultly clearing your nose in the morning? No______Yes______
SINUSITIS: Number of antibiotic therapies taken in last year? ______Last antibiotic therapy (MO/YR)______
Relief from antibiotic therapies: a lot ______somewhat______not much______
Side effects from antibiotics: none______stomach problems______vaginitis______
POST-NASAL DISCHARGE/RUNNING NOSE: A lot______Not much______Never______
Color: green______yellow ______white______clear______
SLEEP DISTURBANCE: No problem______Snoring______Apnea______ENERGY LEVEL: Normal______Low______
DIZZINESS: No______Yes______Please describe:______
DO YOU THINK YOUR SYMPTOMS ARE: progressive______stable______affecting quality of life______
DO YOU MISS WORK/SCHOOL? Yes______No______Days missed per year______
DO YOU HAVE SYMPTOMS: intermittently______daily______incapacitating______
ARE YOUR SINUSES/NOSE PROBLEMS SOMETHING YOU WORRY ABOUT EVERYDAY? No______Yes______
ALLERGIES: Do you think you have: allergies______asthma______eczema______hives______migraine______
Did you have allergy testing done before? Yes_____No______
Did you have allergy shots? Yes______No______How long?______Did the shots help?______
DO YOU USE:______Over-the-counter sprays CURRENT MEDICATIONS:______
______Over-the-counterantihistimines ______
______Cortisone spray ______
______Non-sedative antihistimines ______
______Saline irrigations ______
HAVE YOU HAD: sinus x-ray No______Yes______Results: Normal______Abnormal______
CT scans No______Yes ______Results: Normal______Abnormal______
OPERATIONS: Septalsurgery No______Yes______When:______(yr) Relief from surgery Lot______Little______None_____
Sinus surgery No______Yes______When:______(yr) Relief from surgery Lot______Little______None_____