Nasal Obstruction Symptom Evaluation (NOSE) Form

First Name *

Last Name *

Date of Birth *

Medicare covers rhinoplasty, where the indication for surgery is airway obstruction and the patient has a self-reported Nasal Obstruction Symptom Evaluation (NOSE) Scale Score of >45 or where the indication is significant acquired, congenital or de-velopmental deformity. involving nasal or septal cartilage graft, or nasal bone graft, or nasal bone and nasal cartilage graft,for correction of nasal obstruction or post-traumatic deformity (other than deformity resulting from previous elective cosmetic surgery), or both. Sufficient photographic and /or NOSE Scale evidence demonstrating the clinical need for this service must be included in patient notes .

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

Total Nose score