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Gorden T. McMurry, M.D. EAR, NOSE & THROAT Providing Specialized Care For Your Nose and Sinuses Sinus History
(Please check al answers that apply to you -- front and back) Name______________________________________ DOB____________ Worst Problem: Headache/Facial Pain ____ Hard Time Breathing Through Nose ____ Frequent Sinus Infections____ When Did Symptoms First Start? Early Childhood ____Teen____ Adult____ Since (Mo/Yr) ________________ How many days per month ____ How many hours does the usual headache last?_________ Worse in the: Morning____ Afternoon____ Evening____ Constant pain which gets worse____ Severity: Mild____ Moderate____ Severe____ Quality: Dul ____ Sharp____ Throbbing____ Location: Above the eyes____ Below the eyes____ Behind the eyes_____ Between the eyes____ Top of the head ____ Over the cheeks ____ Back of Head ____ Associated Symptoms: Nausea____ Tearing____ Eye symptoms____ Stuffy Nose _____ Do your symptoms worsen with exposure to: Pressure changes____ Cigarette smoke____ Weather ____ Perfumes____ Cleaning products____ Other____ Hard Time BreathingThrough Nose / Mouth Breathing: Does it get worse when you lie down? Yes____ No____ Which side is affected? Right____ Left____ Always____ Sometimes____ Never____ At night____ Poor Sense of Smel ____ Bad Breath____ Frequent Sore Throat____ Taste____ Frequent throat clearing____ Aching teeth____ Hoarseness____ Cough____ Runny with your nose in the morning? Yes____ No____ Number of antibiotic therapies taken in last year?____ Last antibiotic therapy (Mo/Yr)___________ Relief from antibiotic therapies: Very helpful____ Somewhat helpful____ Not very helpful____ Side effects from antibiotics: None____ Al ergies____ Stomach problems____ Yeast Infections____ List al antibiotics taken in last 12 months: _______________________________________________________ Drainage in Back of Throat / Runny Nose: A lot____ Somewhat____ Not much____ Never____ Color: Green____ Yel ow____ White____ Clear____ Trouble Sleeping: None____ Snoring____ Apnea____ Energy Level: Normal____ Low____ Do You Think Your Symptoms Are? Progressive____ Stable____ Affecting quality of life: Yes___ No___ Do you miss work or school due to sinus disease? Yes____ No____ Average number of days missed per year____ Do your sinus or nasal problems affect your life every day? Yes____ No____ Do you think you have: Al ergies____ Asthma____ Eczema____ Hives____ Migraines____ Have you been tested for al ergies? Yes____ No____ If yes, by whom and when ___________________ Yes___ No___ If yes, how long?_________ Did the shots help? Yes__ No__ Over the counter nose sprays (Vicks™, Afrin™, Duration™, or others) Yes ____ No ____ Over the counter antihistamines (Benadryl™, Tavist™, others) Yes ____ No ____ Prescription antihistamines: Yes ___ No ____ Check al that apply: Hismanal__ Claritin__ Al egra__ Zyrtec__ Astelin™__ Prescription nose sprays: Yes ____ No ____ Please list: _________________________________________________ Have you had: Sinus x-rays Yes____ No____ Results: Normal____ Abnormal____ CT Scans Yes____ No____ Results: Normal____ Abnormal____ Where: _________________ Operations: Nasal septal (breathing) surgery: Yes____ No____ When / Dr. Name?________/________________ Relief from surgery: Yes___ No___ A little___ Relief from surgery: Yes___ No___ A little___ Do you feel you are miserable with sinus problems? Yes___ No___ Do you feel you have received enough medicines for your sinus problems? Yes____ No____ Have you or any one of your family experienced problems with surgical bleeding or anesthesia? Yes ___ No ___ If so,explain: ______________________________________________________________________________________ _________________________________________________________________________________________________ SYMPTOM HISTORY
Grade each symptom from 1-10 with 10 being the worst and 0 for not present Blockage of Nasal Breathing
Eye Pain / Pressure
Throat Pain / Pressure
Runny Nose
Ear Pain / Pressure
Frequent Throat Clearing
Hoarseness
Chronic Cough
Itchy Eyes
Bad Breath
Sneezing
Postnasal Drainage
Watery Eyes
Facial Pain / Pressure
Scratchy Throat
Head Pain / Pressure
Teeth Pain / Aching
Puffy Eyes
General Fatigue
What single problem with your nose and sinuses bothers you most? _______________________________________________________________________________ _______________________________________________________________________________ 4004 Dupont Circle, Suite 220 Louisvil e, Kentucky 40207

Source: http://www.commonwealthent.com/docs/SinusQues.pdf

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