Epistaxis (Nose Bleed) Assessment Questionnaire

Epistaxis Assessment

Epistaxis (Nose Bleed) – Comprehensive ENT Assessment

Patient Details

Name

Age

Sex

Phone Number

Address

Epistaxis Characteristics

Side of Bleeding

Frequency

Severity

Blood flowing into throat

Triggering Factors

Nose picking / trauma

Recent URTI / sneezing

Associated Nasal Symptoms

Nasal obstruction

Facial pain / headache

Systemic History

Hypertension

Bleeding disorder

Liver / kidney disease

Drug History

Anticoagulants / Antiplatelets

Chronic nasal spray use

Provisional Diagnosis

Differential Diagnosis

Recommended Further Work-up