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Patient Questionnaire For CT Scan Sinus
Patient Name
D.O.B.
Date of Exam
Are you seeing an ears, nose and throat doctor (ENT) for you sinus problems?
Yes
No
Please give the name of the ears, nose and throat specialist (ENT):
What symptoms are you having?
Headaches
Yes
No
Excess mucous production
Yes
No
Visual problems
Yes
No
Facial Pain
Yes
No
Other Symptoms (please explain)
How long have you been having these symptoms?
Have you been on antibiotics?
Yes
No
If yes, how long?
Have you had surgery?
Yes
No
If yes, please explain:
Have you had cancer of the face or sinuses?
Yes
No
If yes, please explain:
Have you ever had a fracture of the facial / nasal bones?
Yes
No
If yes, please explain:
Leaders in Subspecialty Imaging
Leaders in Subspecialty Imaging