Sino - Nasal Outcome Test (SNOT - 22)

Below you will find a list of symptoms and social/emotional consequences of your rhinosinusitis.
We would like to know more about these problems and would appreciate your answering the following questions to the best of your ability.
There are no right or wrong answers, and only you can provide us with this information.
Please rate your problems as they have been over the past two weeks.

Considering how severe the problem is when you experience it and how frequently it happens, please rate each item below on how “bad” it is by selecting the answer corresponds with how you feel

Need to blow nose

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

Sneezing

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

Runny Nose

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

Cough

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

Post-nasal discharge (dripping at the back of your nose)

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

Thick Nasal Discharge

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

Ear Fullness

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

Dizziness

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

Ear Pain

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

Facial pain/Pressure

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

Difficulty falling asleep

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

Wake up at night

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

Lack of a good night's sleep

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

Wake up tired

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

Fatigue

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

Reduced productivity

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

Reduced concentration

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

Frustrated/restless/irritable

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

Sad

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

Embarrassed

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

Sense of taste/smell

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

Blockage/congestion of nose

0 - No problem

1 - Very Mild problem

2 - Mild or slight problem

3 - Moderate problem

4 - Severe problem

5 - Problem as bad as it can be

First Name

Surname

DOB

Phone number

Please contact me by email

Please contact me by phone

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How to complete this Questionnaire:

Book Appointment

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Sino – Nasal Outcome Test (SNOT – 22)

How to complete this Questionnaire:

Book Appointment

Have a question?

Refer a Patient