Next page. Name MRN DOB Date. Telephone H W M. Pharmacy

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University of Texas Medical School at Houston Department of Otorhinolaryngology- Head & Neck Surgery Texas Sinus Institute www.ut-ent.org New Patient Questionnaire Rev. 2014-07-19 FINAL REV Page 1 of 7 SCAN THIS PAGE. Name MRN DOB Date Telephone H W M Pharmacy Name Telephone How did you hear about us? Sent by another physician (If so, please give name below.) Sent by a friend Internet search UT and/or TSI reputation Other (Specify) Physician #1 ( sent by this physician) Name Fax Telephone Address City, State Zip Physician #2 ( sent by this physician) Name Fax Telephone Address City, State Zip Important Note on Medical Records and Previous Imaging Please be sure to bring your previous medical records. In particular, previous CT scans and MRI scans of the nose and sinuses are very important. Please try to obtain the actual films (not just the radiology reports); images on CD-ROM are preferable. START HERE: What symptom gives you the most trouble?

Nasal Symptom Inventory Page 2 of 7 The following rating scale will be used to complete the questions: Scale Severity Definition 0 None Absent-NO symptom evident 1 Mild Symptom clearly PRESENT but minimal awareness; easily tolerated 2 Moderate Definite awareness of symptom that is bothersome, but tolerable 3 Severe Symptom is hard to tolerate; interferes with activities of daily living and/or sleeping Using the rating scale above, please rate the following symptoms according to how you feel right now. Facial or sinus pressure (pressure or fullness in the area behind the eyes, cheeks, forehead, or sinuses) Facial or sinus pain (pain in the area around the eyes, cheeks, forehead) Headache (dull to intense, throbbing pain in head) Nasal congestion (stopped up or stuffy nose) Nasal obstruction (inability to move air through the nose) Post-nasal drip (sinus drainage in the back of the throat) Clear nasal discharge (nasal mucus that is clear) Discolored nasal discharge (nasal mucus that is green, yellow, and/or brown) Itchy nose/eyes/throat (sensation of itchiness in the nose, eyes and/or throat) Nose bleeds (bleeding, not bloody mucus, from the nose) Tiredness (feeling worn out or drained due to chronic sinusitis) Wheezing (whistling sound from breathing, associated with chest tightness) Cough None Mild Moderate Severe Sense of smell (reduced sense of smell or detection of bad odor)

Most Important Items Problem as Bad as It Can Be Severe Problem Moderate Problem Mild or Slight Problem Very Mild Problem No Problem Sino-Nasal Outcome Test (SNOT-22) Page 3 of 7 SCAN THIS PAGE. Below you will find a list of symptoms and social/emotional consequences of your rhinosinusitis. We would like to know more about these problems and would appreciate your answering the following questions to the best of your ability. There are no right or wrong answers, and only you can provide us with this information. Please rate your problems as they have been over the past two weeks. Thank you for your participation. Do not hesitate to ask for assistance if necessary. Important: Please mark the most important items affecting your health (maximum of 5 items). Considering how severe the problem is when you experience it and how frequently 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: 1. Need to blow nose 0 1 2 3 4 5 2. Sneezing 0 1 2 3 4 5 3. Runny nose 0 1 2 3 4 5 4. Cough 0 1 2 3 4 5 5. Post-nasal discharge (dripping at the back of your nose) 0 1 2 3 4 5 6. Thick nasal discharge 0 1 2 3 4 5 7. Ear fullness 0 1 2 3 4 5 8. Dizziness 0 1 2 3 4 5 9. Ear pain 0 1 2 3 4 5 10. Facial pain/pressure 0 1 2 3 4 5 11. Difficulty falling asleep 0 1 2 3 4 5 12. Wake up at night 0 1 2 3 4 5 13. Lack of a good night s sleep 0 1 2 3 4 5 14. Wake up tired 0 1 2 3 4 5 15. Fatigue 0 1 2 3 4 5 16. Reduced productivity 0 1 2 3 4 5 17. Reduced concentration 0 1 2 3 4 5 18. Frustrated/restless/irritable 0 1 2 3 4 5 19. Sad 0 1 2 3 4 5 20. Embarrassed 0 1 2 3 4 5 21. Sense of taste/smell 0 1 2 3 4 5 22. Blockage/congestion of nose 0 1 2 3 4 5

General How frequently do you have sinus and nasal symptoms? This is the first episode. 3 times/year 4-6 times per year Monthly Weekly Daily Constantly Do your symptoms improve between episodes?, they completely improve, they never improve Sometimes, they improve They improve partially How often do your baseline symptoms get worse? Never (The symptoms are always the same.) 1-3 times/year 4-6 times per year More than 6 times per year Which best describes your sense of smell? problem with sense of smell Diminished sense of smell Loss of smell Detect bad odor Have you ever had a sinus CT or MRI scan? If yes, please provide details (including dates) below. Allergy Page Do you have any of these allergy symptoms? Sneezing fits Itchy ears Itchy eyes Itchy nose Runny nose Itchy throat Runny/watery eyes Scratchy roof of your mouth When are your allergy symptoms most apparent? Spring Summer Fall Winter Continuously throughout the year Have you ever been tested for allergy? Never I have had skin testing for allergy. I have had blood testing for allergy. Have you received allergy shots? Never, and they helped a great deal., and they helped somewhat., and they did nothing. Asthma Do you have asthma? Page 4 of 7 If yes, what do you take for your asthma? Asthma inhalers Nebulizer treatments Oral steroids Theophylline Other Have you ever had a sinus or nasal surgery? If yes, please provide details (including dates) below. Trauma Have you ever broken your nose? Have you ever sustained other facial and/or head injuries?

Previous Treatments Which antibiotics have you received over the past year? Amox and/or PCN Amox/clav (Augmentin) Azithromycin (Zithromax, Z-pak) Cefadroxil (Duricef) Cefdinir (Omnicef) Cefpodoxime (Vantin) Cefprozil (Cefzil) Cefuroxime (Ceftin) Cephalexin (Keflex) Ciprofloxacin (Cipro) Clarithromycin (Biaxin) Erythromycin Levofloxacin (Levaquin) Loracarbef (Lorabid) Moxifloxacin (Avelox) SMP/TMX (Bactrim, Sulfa) IV antibiotics ne Which antihistamines have you received over the past year? Cetirizine (Zyrtec) Cetirizine/decongestant (Zyrtec-D) Desloratadine (Clarinex) Desloratadine/decongestant (Clarinex-D) Diphenhydramine (Benadryl) Fexofenadine (Allegra) Fexofenadine/decongestant (Allegra-D) Levocetirizine (Zyzal) Loratadine (Claritin) Loratadine/decongestant (Claritin-D) ne Page 5 of 7 Which nasal sprays have you used over the past year? Beclomethasone (Qnasal, Beconase) Budesonide (Rhinocort) Ciclesonide (Omnaris) Flunisolide (Nasarel) Fluticasone furoate (Veramyst) Fluticasone propionate (Flonase) Mometasone (Nasonex) Triamcinolone (Nasacort) Oxymetazoline (Afrin) Azelastine (Astelin) Fluticasone/azelastine (Dymista) Olopatadine (Patanase) Ipratropium bromide (Atrovent) ne What other treatments have you used over the past year? Montelukast (Singulair) Zileuton (Zyflo) Antifungal treatments Guaifenesin OTC (Mucinex) Nasal saline sprays Nasal saline irrigations Oral decongestants Systemic steroids Topical antibiotic irrigations/treatments ne

Treated by another physician No Yes Treated by another physician No Yes Page 6 of 7 Review of Systems The following is a list of common symptoms and health problems. Please review the list and indicate with a check mark the symptoms and health problems that you are experiencing. General Gastro-intestinal Nausea Heartburn Weight gain Belly pain Weight loss Diarrhea Fevers/chills Constipation Ears, Nose & Throat Vomiting Hoarseness Skin Hearing loss Rashes Draining ear Ulcers Vertigo Musculo-skeletal Loud snoring Muscle pain Daytime sleepiness Muscle weakness Mouth sores Endocrine Tooth problems Painful/difficult swallowing Ringing in the ears Eyes Cold intolerance Heat intolerance Excessive thirst Hematologic Double vision Anemia Blurry vision Bleeding Cardiac Bruising Chest pain Neurological Short of breath Seizures Respiratory Psychiatric Wheezing Depression Cough Anxiety

Page 7 of 7 Past History Do you have any of the following medical problems? Arthritis Asthma Bleeding disorder Cataracts Chronic fatigue syndrome Depression Diabetes Fibromyalgia Gastritis Glaucoma Hepatitis High blood pressure Heart disease Immunodeficiency Kidney disease Meningitis Migraine headache Mitral valve prolapse Peptic ulcer disease Seizures Thyroid disease Tuberculosis (TB) Please list your previous surgical procedures. Please list your current medications. Are you allergic to any medications? (If yes, please give details.) Family History Do any of your family members have any of the following conditions? (Please specify the family member.) Allergy Asthma Bleeding disorder Cancer Social History What is your occupation? Cystic fibrosis Heart disease Immunodeficiency Please list your previous hospitalizations. Do you have any other medical problems not listed above? (If yes, please give details.) Have you had any recent change in your home or work environment? Do you smoke? Do you drink alcoholic beverages? Have you ever used cocaine or other illicit substances?.

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