Sinus Procedure Survey

We hope that your sinus procedure created results that exceeded your expectations. The performance of Dr. Girigs is very important to us, so we ask that you please share some details of your experience by answering the questions below. Your answers are confidential and will be used to optimize the level of our services.

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Contact Information

First Name :

Last Name :

Address 1 :

Address 2 :

City :

State :

Zip :

Phone :

Email Address :

Please rate the satisfaction with the overall quality of your care.

Excellent

Good

Poor

What kind of experience did you receive from the operation?

Major Improvement

Moderate Improvement

No Improvement

More Complications

Are you/were you on medication? If yes, do you require less/no medication since the procedure?

Yes, I require less/no medication

Yes, but I require more medication

Are you asthmatic? If yes, do you experience relief of asthma symptoms since the procedure?

Yes, I experience relief in my asthma symptoms

Yes, but the procedure did not effect my asthma

Did you follow proper postsurgical procedures such as taking antibiotics, steam inhalants, avoided smoking, alcohol, swimming, and attending follow up appointments?

Yes

Rate the relief of these symptoms:

	Major Improvement	Moderate Improvement	No Improvement	Symptoms Worsened	Did Not Experience Symptom
Nasal Obstruction

Post Nasal Drip

Facial Pain

Headaches

Congestion

Sneezing

Ability to Smell

Ability to Taste

After noticing discomfort how long did you allow the symptoms to persist before you visited Dr.Girgis?

Immediately

Days

Weeks

Months

Years

Would you recommend this procedure to a friend who had the same symptoms?

Yes

We would be greatly appreciated if you could share your experience with a testimonial in the box below.

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