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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. Thank you for your participation. Do not hesitate to ask for assistance if necessary.

Considering how severe the problem is when you experience it and how often it happens, please rate each item below on how “bad” it is by selecting the number/item that corresponds with how you feel using this scale:

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Patient Full Name*
Date of Birth*
MM slash DD slash YYYY
Mobile*
1. Need to blow nose:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
2. Nasal Blockage:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
3. Sneezing:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
4. Runny nose:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
5. Cough:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
6. Post-nasal discharge:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
7. Thick nasal discharge:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
8. Ear fullness:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
9. Dizziness:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
10. Ear pain:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
11. Facial pain/pressure:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
12. Decreased Sense of Smell/Taste:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
13. Difficulty falling asleep:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
14. Wake up at night:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
15. Lack of a good night’s sleep:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
16. Wake up tired:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
17. Fatigue:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
18. Reduced productivity:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
19. Reduced concentration:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
20. Frustrated/restless/irritable:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
21. Sad:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
22. Embarrassed:
No Problem
0 Very Mild Problem
1 Mild or slight Problem
2 Moderate Problem
3 Severe Problem
4 Problem as bad as it can be
5
Please mark the most important items affecting your health (maximum of 5 items)*
- Need to blow nose
- Nasal Blockage
- Sneezing
- Runny nose
- Cough
- Post-nasal discharge
- Thick nasal discharge
- Ear fullness
- Dizziness
- Ear pain
- Facial pain/pressure
- Decreased Sense of Smell/Taste
- Difficulty falling asleep
- Wake up at night
- Lack of a good night’s sleep
- Wake up tired
- Fatigue
- Reduced productivity
- Reduced concentration
- Frustrated/restless/irritable
- Sad
- Embarrassed