Daily Symptom Diary
1. Time of Entry:
2. Discomfort Level (0-10):
Select...
0 (No discomfort)
1
2
3
4
5
6
7
8
9
10 (Worst possible discomfort)
3. Discomfort Description (Select all that apply):
Pressure
Pinching
Throbbing
Sharp pain
Dull ache
Tingling
Numbness
Other
4. Body Position (Select all that apply):
Standing
Sitting
Lying down - Face up
Lying down - Left side
Lying down - Right side
Bending over
Moving around
Other
5. Activity (Select all that apply):
Resting
Working (desk work)
Physical activity
Eating or drinking
Driving
Reading or watching TV
Other
6. Environment:
Location:
Indoors
Outdoors
Air Quality (Select all that apply):
Fresh air
Air-conditioned
Heated
Humid
Dry
Presence of allergens
Poor air quality
7. Sinus and Related Symptoms (Select all that apply):
Nasal congestion
Runny nose
Post-nasal drip
Facial pressure/pain
Headache
Ear fullness/pressure
Sore throat
Cough
Reduced sense of smell/taste
Other
8. Relief Measures Taken (Select all that apply):
Changed body position
Applied warm compress
Performed nasal irrigation
Took pain reliever
Took decongestant
Took antihistamine
Drank fluids
Used humidifier
Rested
Other
9. Effectiveness of Relief Measures (0-5):
Select...
0 (No relief)
1
2
3
4
5 (Complete relief)
10. Additional Notes (Optional):
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