Funtional Nasal Form - Bahman Guyuron, MD - Zeeba Clinic

Patient's name *

Date

Do you have any difficulty breathing through your nose?
YesNo

Do you experience headache?
YesNo

Are you a mouth breather?
YesNo

Do you snore?
YesNo

Do you find it difficult to breath when lying down?
YesNo

Do you use any of these?

Nasal irrigation or sprays
YesNo

if yes, please list them:

Vaporizer? Humidifier?
YesNo

Do you wake up at night due to breathing problems?
YesNo

Do you find yourself tired during day?
YesNo

If yes, does it interfere with your daily job and performance?
YesNoN/A

Do your breathing problems interfere with your activities like running, sport or other activities?
YesNoN/A

Have you seen any doctor for breathing problem?
YesNo

if yes. please name the Doctor and treatment

Was the treatment successful?
YesNoN/A