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 |