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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 First Name Last Name Email Phone Time's up