1. Need to blow nose 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None 2. Sneezing 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None 3. Runny Nose 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None 4. Cough 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None 5. Post-nasal discharge (dripping at the back of your nose) 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None 6. Thick Nasal Discharge 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None 7. Ear Fullness 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None 8. Dizziness 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None 9. Ear Pain 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None 10. Facial pain/Pressure 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None 11. Difficulty falling asleep 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None 12. Wake up at night 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None 13. Lack of a good night's sleep 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None 14. Wake up tired 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None 15. Fatigue 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None 16. Reduced productivity 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None 17. Reduced concentration 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None 18. Frustrated/restless/irritable 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None 19. Sad 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None 20. Embarrassed 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None 21. Sense of taste/smell 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None 22. Blockage/congestion of nose 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be None First Name Last Name Email Phone Time's up
