Symptoms History Survey In order to discover if you are susceptible we need some information about some of your past medical history, please take your time and answer all the questions. Personal Information All information is required. First Name: Last Name: Address: City: State:         Select a State       AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMarylandMaineMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOK - OklahomaOhioOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAlberta, CanadaNew Brunswick, CanadaOntario, Canada Zip: Phone: Email:   Symptom History Have you had a sinus infection in the past year? Have you taken an antibiotic in the last year? Do you have sinus headaches (not migraine)? Have you had asthma? Have you had aspirin allergy? Have you had bronchitis? Do you have loss of smell? Do you have nasal airway obstruction? Do you have post nasal drip? Do you have an allergy either to dust, mold, or mildew? Have you been tested for allergies? Have you ever taken allergy shots? Have you had drainage from the nose? Have you had sinus surgery? Do you have fibromyalgia? Do you have brain fog (neurocognitive dysfunction)? Do you have problem concentrating or remembering? Do you have lupus? Do you have cancer? Do you have muscle and/or joint pain? Do you have fatigue and/or weakness? Do you have sinusitis? Do you have headaches? Do you have gastrointestinal problems? Do you have shortness of breath? Do you have anxiety, depression or irritability? Do you have vision problems? Do you have chest tightness? Do you have insomnia? Do you have dizziness? Do you have hearing loss? Do you have ringing in your ears? Do you have fullness in your ears?
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