Please answer all questions to the best of your ability. This information will assist us in understanding and treating your symptoms. 1a. Please rate how your nasal congestion has been over the past 12 hours None Mild (symptom clearly present but easily tolerated) Moderate (symptom bothersome but tolerable) Severe (symptom difficult to tolerate – interferes with activities) 1b. Please rate how your nasal congestion has been over the past 2 weeks None Mild (symptom clearly present but easily tolerated) Moderate (symptom bothersome but tolerable) Severe (symptom difficult to tolerate – interferes with activities) 2a. Please rate how your runny nose has been over the past 12 hours None Mild (symptom clearly present but easily tolerated) Moderate (symptom bothersome but tolerable) Severe (symptom difficult to tolerate – interferes with activities) 2b. Please rate how your runny nose has been over the past 2 weeks None Mild (symptom clearly present but easily tolerated) Moderate (symptom bothersome but tolerable) Severe (symptom difficult to tolerate – interferes with activities) 3a. Please rate how your nasal itching has been over the past 12 hours None Mild (symptom clearly present but easily tolerated) Moderate (symptom bothersome but tolerable) Severe (symptom difficult to tolerate – interferes with activities) 3b. Please rate how your nasal itching has been over the past 2 weeks None Mild (symptom clearly present but easily tolerated) Moderate (symptom bothersome but tolerable) Severe (symptom difficult to tolerate – interferes with activities) 4a. Please rate how your sneezing has been over the past 12 hours None Mild (symptom clearly present but easily tolerated) Moderate (symptom bothersome but tolerable) Severe (symptom difficult to tolerate – interferes with activities) 4b. Please rate how your sneezing has been over the past 2 weeks None Mild (symptom clearly present but easily tolerated) Moderate (symptom bothersome but tolerable) Severe (symptom difficult to tolerate – interferes with activities) 5a. Please rate how difficult sleep has been with nasal symptoms last night None Mild (symptom clearly present but easily tolerated) Moderate (symptom bothersome but tolerable) Severe (symptom difficult to tolerate – interferes with activities) 5b. Please rate how difficult sleep has been with nasal symptoms the past 2 weeks None Mild (symptom clearly present but easily tolerated) Moderate (symptom bothersome but tolerable) Severe (symptom difficult to tolerate – interferes with activities) First Name Last Name Email Phone Date of Birth Time's up
