Are you a candidate for balloon sinuplasty?

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The following questionnaire is intended to help define your symptoms and provide valuable information and insights for your doctor. Answer the questions, rating to the best of your ability the problems you have experienced over the past two weeks.

Consider how severe the problem is when you experience it and how frequently it happens, please rate each item how “bad” it is by selecting the severity below.

Need to blow nose
Sneezing
Runny nose
Cough
Post-nasal discharge
Thick nasal discharge
Ear fullness
Dizziness
Ear pain
Facial pain/pressure
Difficulty falling asleep
Wake up at night
Lack of sleep
Wake up tired
Fatigue
Reduced productivity
Reduced concentration
Frustrated/restless/irritable
Sad
Embarrassed

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