The following questionnaire is intended to help define your symptoms and provide valuable information and insights for your doctor. Answer the questions, rating to the best of your ability the problems you have experienced over the past two weeks.
Sino-Nasal Outcome Test (SNOT-20)
 Patient Name (required)     Patient Phone     Date    
Considering how severe the problem is when you experience it and how frequently it happens, please rate
each item below on how “bad” it is by selecting the number that corresponds with how you feel.

In the last column, please check the most important items affecting your health (maximum of 5 items).
No
problem
Very mild
problem
Mild or
slight
problem
Moderate
problem
Severe
problem
Problem
as bad as
it can be
5 most
important
items
  1. Need to blow nose
  2. Sneezing
  3. Runny nose
  4. Cough
  5. Post-nasal discharge
  6. Thick nasal discharge
  7. Ear fullness
  8. Dizziness
  9. Ear pain
10. Facial pain/pressure
11. Difficulty falling asleep
12. Wake up at night
13. Lack of sleep
14. Wake up tired
15. Fatigue
16. Reduced productivity
17. Reduced concentration
18. Frustrated/restless/irritable
19. Sad
20. Embarrassed
©1996 by Jay F. Picirillo, M.D., Washington University School of Medicine, St. Louis, Missouri