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Nasal/Sinus Survey
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Patient's Name:
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Address1:
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Address2:
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City:
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State:
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Zip:
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Home Phone:
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Work Phone:
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Gender:
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Patient Marital Status:
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Patient Date of Birth:
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Patient Age:
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Symptoms
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What are your symptoms?
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How long have you had this problem?
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Do you know the cause of your problem?
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If yes, what?
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Do you have nasal congestion or stuffiness?
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Do you use an over-the-counter nasal spray?
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What brand?
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Do you have post-nasal drip?
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What type?
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What time of day is it worst?
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