1. How many sinus infections have you had in the past year?

2. How many times a month do you have sinus headaches (not migraines)?

3. How many times have you taken antibiotics in the last year?

4. Have you had aspirin allergy?

5. Do you have loss of smell?

6. Do you have nasal airway obstruction?

7. Do you have postnasal drip?

8. Do you have allergies (non-food)?

9. How many sinus surgeries have you had?

10. Has the furnace or air conditioner location in your home ever been damp?

11. Is the heater or air conditioner located in a dirt crawl space?

12. Is your crawl space damp?

13. Is the heater located in the attic with blown-in insulation?

14. Do you have a humidifier in the central furnace?

15. Have you had a leak or flood anywhere in your home?

16. Do you ever notice a musty smell in the house?

17. Have you noticed any mold in the house (other than the bathroom shower/tub)?

18. Do you feel better (physically) away from home

19. Do you feel better (physically) away from the office?

20. Do you or your co-workers feel bad at the office?

21. Do you feel better if you go to the beach or other clean air space?

22. Do you have pets in the home?

23. Do you sleep with your pets?

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

25. Do you have any of the following? (Check all that apply)