Please rate each item below by circling the number that corresponds to how you feel, using the following scale:

No

Problem

Very

Mild

Problem

Mild

Problem

Moderate

Problem

Severe

Problem

Very

severe

problem

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. Nasal obstruction

0

1

2

3

4

5

5. Loss of smell or taste

0

1

2

3

4

5

6. Cough

0

1

2

3

4

5

7. Post-nasal discharge

0

1

2

3

4

5

8. Thick nasal discharge

0

1

2

3

4

5

9. Ear fullness

0

1

2

3

4

5

10. Dizziness

0

1

2

3

4

5

11. Ear pain

0

1

2

3

4

5

12. Facial pain/pressure

0

1

2

3

4

5

13. Difficulty falling asleep

0

1

2

3

4

5

14. Waking up at night

0

1

2

3

4

5

15. Lack of a good night’s sleep

0

1

2

3

4

5

16. Waking up tired

0

1

2

3

4

5

17. Fatigue

0

1

2

3

4

5

18. Reduced productivity

0

1

2

3

4

5

19. Reduced concentration

0

1

2

3

4

5

20. Frustrated/restless/irritable

0

1

2

3

4

5

21. Sad

0

1

2

3

4

5

22. Embarrassed

0

1

2

3

4

5