1. 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 ticking the radio button that corresponds with how you feel.

2. Please mark the most important items affecting your health (maximum of 5 items).

No problem Very mild problem Mild or slight problem Moderate problem Severe problem Problem as bad as it can be
  0 1 2 3 4 5
1. Need to blow nose
2. Sneezing
3. Runny nose
4. Cough
5. Post-nasal discharge
6. Thick nasal discharge
7. Ear fullness
8. Dizziness
9. Ear pain
10. Facial pain / pressure
  No problem Very mild problem Mild or slight problem Moderate problem Severe problem Problem as bad as it can be
  0 1 2 3 4 5
11. Difficulty falling asleep
12. Wake up at night
13. Lack of sleep
14. Wake up tired
15. Fatigue
16. Reduced productivity
17. Reduced concentration
18. Frustrated / restless / irritable
19. Sad
20. Embarrassed