Nasal mass assessment questionnaire Nasal Mass Assessment Questionnaire Nasal Mass Assessment Questionnaire Patient Details Patient Name Age Sex Male Female Other Phone Number Address History of Present Illness Side of Nasal Mass Unilateral Bilateral Duration of Symptoms < 2 weeks 2 weeks – 3 months > 3 months Rate of Growth Slow growing Rapidly increasing Nasal Obstruction None Partial Complete Epistaxis Absent Occasional Recurrent / Profuse Nasal Discharge None Mucoid Mucopurulent Foul smelling Blood stained Facial Pain / Pressure Absent Present Reduced Sense of Smell No Yes Headache No Yes Associated & Alarm Symptoms Visual disturbance / Diplopia Eye protrusion Loosening of teeth Palatal swelling Neck swelling Weight loss Past & Personal History History of Allergy / Asthma No Yes Diabetes / Immunocompromised State No Yes Smoking / Tobacco Use No Yes Previous Nasal Surgery No Yes Generate Provisional Diagnosis Advanced nasal mass assessment questionnaire Advanced Nasal Mass Assessment Advanced Nasal Mass Assessment Questionnaire Patient Demographics Name Age Sex MaleFemaleOther Phone Address History of Present Illness Laterality BilateralUnilateral Duration < 2 weeks 2 weeks – 3 months > 3 months Growth Pattern SlowRapid Nasal Obstruction NonePartialComplete Epistaxis AbsentOccasionalRecurrent / Profuse Discharge None Mucoid Mucopurulent Thick, sticky, dark Foul smelling Blood stained Facial Pain / Pressure NoYes Loss of Smell NoYes Associated ENT Symptoms Unilateral ear blockage / hearing loss Change in voice / nasal speech Persistent headache Red Flag Symptoms Visual disturbance / diplopia Proptosis Facial numbness Trismus Palatal swelling Past / Personal History Allergy / AsthmaNoYes Diabetes / ImmunocompromisedNoYes Smoking / TobaccoNoYes Previous nasal surgeryNoYes ENT Examination (Clinician Filled) Endoscopic Appearance Pale, edematous Pink, lobulated Reddish, vascular Blackish / necrotic Irregular / ulcerative Bleeds on Touch NoYes Attachment Middle meatusSeptumLateral wallNasopharynx Cervical Lymph Nodes Not palpable Palpable, tender Palpable, non-tender, hard Generate Provisional Diagnosis
