Physician Name: _________________________________________________

Practice Name: __________________________________________________

Hospital Affiliation: ________________________________________________

Contact Phone Number: ___________________________________________

Date of Visit: ____________________

1. What is my diagnosis?

2. How do you recommend treating my form of sinusitis?

3. Will you put me on medications? If so, what are they and are there any side effects?

4. Can my sinusitis have long-term effects on my overall health?

5. Is surgery possible in my future?

6. What measures can be taken at home to relieve my sinus pain?

7. Will any changes in my lifestyle be necessary?

8. Will my insurance cover this treatment?

9. How often will I be required to see you?

10. Whom should I call in your office if I have more questions?

Disclaimer: The above list is not meant to be all-inclusive. You may want to disregard some of these questions or add questions of your own.

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