PATIENT'S NAME ______________________________________

PATIENT'S SIGNATURE__________________________________

ADDRESS ____________________________________________

ADDRESS ____________________________________________

PHONE NUMBER ______________________________________

SURGEON ____________________________________________

DATE OF SURGERY ____________________________________

You (or your child) are to have surgery in the near future. 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 5 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

* 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.