PATIENT'S NAME ______________________________________

ADDRESS ____________________________________________

ADDRESS ____________________________________________

PHONE NUMBER ______________________________________

SURGEON ____________________________________________

DATE OF SURGERY ____________________________________

You (or your child) had surgery performed in the past year. For the benefit of all our patients and physicians, we are trying to determine how successful our recommended surgeries are in eliminating the patient's problems. We ask you to take a minute and answer the following 8 questions.

Rate the following symptoms you (or your child) currently have on a scale of 0 to 4 with 0 being no symptoms at all and 4 being the most severe symptoms.

1. HEADACHE	0	1	2	3	4
2. NASAL OBSTRUCTION	0	1	2	3	4
3. NASAL DISCHARGE OR     POST NASAL DRAINAGE	0	1	2	3	4
4. MISSED SCHOOL OR WORK	0	1	2	3	4
5. NEED FOR DOCTOR VISITS     AND/OR MEDICINES	0	1	2	3	4

6. Overall compared to before the surgery, are your symptoms:
Resolved	Better	About the Same	Worse
7. Did the surgery meet your goals and expectations?
Yes	No
8. Would you still have the surgery if you had the whole thing to do over again?
Yes	No

* Please print this form, complete it and bring or mail it to our office. Our mailing address can be obtained from our Office Information page.