Quick Patient Questionnaire:
Change answer to 'YES' if you have suffered from
any of the following symptoms for ten days or longer
in the past month:

Facial pressure/pain?	YES	NO
Headache pain?	YES	NO
Congestion or stuffy nose?	YES	NO
Thick, yellow-green nasal discharge?	YES	NO
Low fever (99-100°)?	YES	NO
Bad breath?	YES	NO
Pain in the upper teeth?	YES	NO
Have you experienced these symptoms for twelve or more consecutive weeks?	YES	NO
Have you experienced these symptoms for 10 or more days three, four, five or more times (with periods of no symptoms) in the last twelve months?	YES	NO
Please provide your Name: How do you wish for us to contact you: