Sinus Questionnaire - HomeopathicVibes

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Sinus Questionnaire

Why Me?

I'm providing homeopathic services for over 20 years in entire California. My clinic is located in Sunnyvale, Fremont, and San Jose. I have treated more than 1000 patients suffering from various conditions. I also provide online consultation if you're not able to visit any of my clinics. I have more than 100 five stars reviews on Google, Yelp, and other reviews websites. If you would like to know more about me, then feel free to reach me out by phone.

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Sinus Questionnaire

940 E. El Camino Real
Sunnyvale, CA 94087
harminder@homeopathicvibes.com
www.homeopathicvibes.com
Office Phone (408)737-7100
Office Fax (408)737-7102

Name *

First

Last

Do you think you have sinus problems?

Yes
No

If yes, for how long?

Do you have Nasal Congestion (difficulty breathing through the nose)?

Yes
No

Yes, this is my main complaint.

Is this congestion/obstruction

Constant
Intermittent

Which side is worse?

Right side
Left side
Both sides are stuffy

For how long have you had nasal congestion/obstruction?

Less than 2 months
One year or less
Between one and two years
longer

Do you have discharge or drainage from your nose?

Yes
No

Is the drainage or discharge mainly from the?

Front of nose
Back of nose into throat (post nasal drip)
From both areas

Is there a great deal of discharge?

Yes
No

What if the quality of the drainage or discharge?

Watery
Tenacious(thick)

What is the color of the discharge?

Clear
White(opaque)
Discolored(yellow, green etc.)

Is your sense of smell

Good
Poor: I notice a bad smell (odor)
Yes
No

Are headaches or facial pain part of your sinus symptoms?

Yes
No
Yes, this is my main complaint

How long have you had headaches/pain?

Less than 2 months
Less than 2 years
More than 2 years
Others

Where do you feel this headache/pain?

Forehead
Top of the head
Upper teeth
Inner angle of the eye
Bridge of nose
Behind eye(s)
Others

How would you describe this pain?

Pressure
Throbbing
Sharp
Others

Does your headache/pain get worse with a cold?

Yes
No With flying?
Yes
No

How many infections have you had this past year? Last year(number)

What other sinus-related complaints do you have?

Do you have allergies?

Yes
No
I don't know

Have you had allergy testing?

Yes
No

I am allergic to

Have you taken allergy shots?

Yes
No If yes

When

Do you or have had asthma or asthmatic bronchitis?

Yes
No

What medicines do you take for asthma or bronchitis?

Please indicate the types (and names) of drugs used to treat your sinus problem. ANTIBIOTICS

Yes
No (if yes, identify below)
AMOXACILLIN
AVELOX
CEFTIN
AUGMENTIN
SEPTRA
CIPRO
LEVAQUIN
TEQUIN
KETEX

Other

Have antibiotics helped

Yes
No
Temporarily or partially

ANTIHISTAMINE and/or DECONGESTANT:

Yes
No

Have these medications helped?

Yes
No
Temporarily or partially

STEROID NASAL SPRAY:

Yes [Rhinocort, Nasonex, Flonase, Nasacort, Nasarel]
No

Have these sprays helped?

Yes
No
Temporarily or partially

ORAL STEROIDS

Yes [Prednisone, Medrol]
No

Have these medications helped?

Yes
No
Temporarily or partially

Do you use saline or another sinus wash?

Yes
No

Have you had any previous nasal or sinus surgery?

Have you taken any alternative medicines in the past?

Homeopathy
Ayurveda
Acupressure or Acupuncture

How long did you use them?

Less than 2 months
More than 2 months
More than 6 months
Others

Have any of these helped?

Yes
No
Temporarily or partially

Message

About Me

I have passion for homeopathy. I am blessed to be born in family of Homeopaths. My grand father Dr. Hazara Singh Gill was great homeopath of his times. He did his M.B.H (Bachelor of Medicine in Homeopathy) from Punjab Homeopathic Medical College Lahore in 1925.

Sunnyvale Location

Phone: 408-737-7100
Fax: 408-737-7102
Address: 940 E El Camino Real, Sunnyvale, CA 94087, United States
harminder@homeopathicvibes.com

Fremont Location

Phone: 408-737-7100
Fax: 408-737-7102
Address: 39039 Paseo Padere Parkway,Suite #209,Fremont, CA 94538, USA.
harminder@homeopathicvibes.com

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