RHINITIS SYMPTOM QUESTIONNAIRE

 

This questionnaire will help determine if RINAR may be appropriate for your symptoms. Please complete the following questions to see if RINAR may be suitable for you.

 

Q1. Do you regularly experience any of the following symptoms?

 

Blocked and stuffy nose Yes
Sensitive or irritated nose Yes
Facial pain Yes
Runny nose and/or post nasal drip Yes
Excessive sneezing Yes

 

 

Q2. Please tick all the things that you think make your symptoms worse:

 

Rhinitis Triggers
Mowed grass Smoke
Dead grass Perfume/cologne
Hay Soaps
Flowers Cosmetics
Pollen Cleaning products
Trees Paint fumes
Weeds Hairspray
House dust Exhaust fumes
Cat/cat hair Sawdust
Dog/dog hair Pine odour
Feathers Petrol fumes
Mould Air conditioning
    Weather and temperature changes
    Spicy food
    Alcohol

 

Table adapted from Dykewicz et al 199811 and Cincinnati irritant index scale12

 

 

Q3. Do you find anti-histamine tablets give you little or no relief from your symptoms?

Yes     No     I never use anti-histamine tablets

 

 

 

Always read the label. Use only as directed. If symptoms persist see your healthcare professional.