Sinusitis Self-assessment

What to Expect with NuVent®

Take this quick self-assessment to help you and your doctor determine if you are a good candidate for balloon sinus surgery with the NuVent® EM Sinus Dilation System.
Simply rate each item according to your experience. After you have finished rating all of the items on this form, print the form and review it with your doctor.
1 Have you visited an ear, nose, and throat (ENT) specialist?
YES NO
2 Have you been diagnosed with sinusitis?
YES NO I DON'T KNOW
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
Condition
0 1 2 3 4 5
Headache
Neck tension
Neck pain
Needing to blow nose
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
Condition
0 1 2 3 4 5
Runny nose
Cough
Postnasal drip
Thick nasal discharge
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
Condition
0 1 2 3 4 5
Dizziness
Pain under eyes
Pain behind eyes
Throbbing in cheeks
"Pulling" in ear
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
Condition
0 1 2 3 4 5
Forehead pain
Pain on top part of nose
Ear pain
Facial pain/pressure
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
Condition
0 1 2 3 4 5
Waking up at night
Lack of a good night's sleep
Waking up tired
Fatigue
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
Condition
0 1 2 3 4 5
Reduced concentration
Frustration/restlessness/irritability
Sadness
Embarrassment
1 2 3 4 5 6 7