Nasal Obstruction Symptom Evaluation (NOSE) Form

First Name *

Last Name *

Date of Birth *

Over the past 1 month, how much of a problem were the following conditions for you?

Unable to get enough air through my nose during exercise or exertion *

Is your nose blocked on one or both sides? *

One sideBoth sidesSwitches between sidesNot blocked

Is your nose blockage worse when you lie down or turn over in bed ? *

YesNo

For the following questions, please check the box that most suits the level of difficulty you are having with your breathing with '0' representing no problem and '9' meaning that your difficulty is as bad as it can be