Your Free Personal Evaluation Your Email Address: Your First Name: Submit Section 1: Sinus History 1. How many sinus infections have you had in the past year? 012345+ 2. How many times a month do you have sinus headaches (not migraines)? 012345+ 3. How many times have you taken antibiotics in the last year? 012345+ 4. Have you had aspirin allergy? NoYes 5. Do you have loss of smell? NoYes 6. Do you have nasal airway obstruction? No blockageOccasionallyAt night your nose feels stopped upFairly frequentlyCompletely blocked on one or both sides all the time 7. Do you have postnasal drip? NoneRarelyOccasionallyFrequentlyMost of the time 8. Do you have allergies (non-food)? YesNo 9. How many sinus surgeries have you had? 012345Section 2: Your Environment 10. Has the furnace or air conditioner location in your home ever been damp? NoYes 11. Is the heater or air conditioner located in a dirt crawl space? NoYes 12. Is your crawl space damp? NoYes 13. Is the heater located in the attic with blown-in insulation? NoYes 14. Do you have a humidifier in the central furnace? NoYes 15. Have you had a leak or flood anywhere in your home? NoYes 16. Do you ever notice a musty smell in the house? NoYes 17. Have you noticed any mold in the house (other than the bathroom shower/tub)? NoYes 18. Do you feel better (physically) away from home NoYes 19. Do you feel better (physically) away from the office? NoYes 20. Do you or your co-workers feel bad at the office? NoYes 21. Do you feel better if you go to the beach or other clean air space? NoYes 22. Do you have pets in the home? NoYes 23. Do you sleep with your pets? NoYesSection 3: Additional History 24. Do you experience fatigue or tiredness regularly? Rate your level of fatigue: 0=can walk 5 miles 10=can't get out of bed 012345678910 25. Do you have any of the following? (Check all that apply) Abdominal painMemory loss and/or problems concentratingOther neurocognitive dysfunctionFood AllergiesAttention Deficit Disorder (ADD)Blurred visionConstipationChest tightnessDiabetesInsomniaDiarrheaNumbness/tinglingBloating and/or gasLaryngitisStomach PainAnxiety, depression, or irritability?Gut Problems ( Enteropathy)Leaky Gut SyndromeGluten SensitivitySkin rashesPsoriasisEczemaLoss of protein in gutHivesGastritis (Stomach inflammation)Urticaria (itching)Cloitis (bowel inflammation)Tremors/seizuresHyperactivityShortness of breathHypoglycemia (low blood sugar)CancerInterstitial cystitis (bladder inflammation)LymphomaMigrainesLeukemiaObesityLupusMuscle and/or joint pain/fibromyalgiaEsophageal acid refluxWeaknessAsthmaBronchitis Loading... Print Was this Post Meaningful? Please Share! Share This Story, Choose Your Platform! FacebookTwitterRedditLinkedInTumblrPinterestVkEmail About the Author: Sinusitis Wellness