To help Dr. Shuaib provide you with fast and efficient service, we kindly ask you to complete the following:

*The information provided in this form will be kept strictly confidential*

1. Do you currently suffer from sinus pain?
YesNo

2. On a scale of 1 -10, 10 being very severe, please rate your discomfort level:

3. Do you have a nasal drip?
YesNo

4. Do you suffer from sinus headaches?
YesNo

5. Are your sinuses usually congested or blocked?
YesNo

6. Do you currently use nasal steroid sprays like Nasonex® or Flonase®?
YesNo

7. Are you having difficulty breathing through your nose?
YesNo

8. Do you feel you suffer from drainage from front or back of the Nose?
YesNo

9. Do you have problems with your sense of smell?
YesNo

10. Are you having a chronic cough?
YesNo

Would you like our offices to contact you to set an appointment with Dr. Shuaib?
YesNo