What is your date of birth?

Do you experience face pain, problems breathing from the nose, and nasal discharge?

STOP HERE if you do not have sinus infection symptoms. We only evaluate for sinus infections.

YesNo

Do you experience any of the following symptoms?

SneezingRunny noseCoughPost nasal dischargeThick nasal dischargePain in the forehead, behind the eye(s)Pain on one side/both sides of the face, the cheek 🡪 One or both sides?Facial pressureLack of a good night’s sleepHeadache around the entire headFever 38.3 C or higherBad breath

When did you start getting sick?

Less than 1 week agoMore than 1 week ago, but less than 2 weeks (8 to 14 days)15 days or more

Do you have thick, yellow-green nasal discharge?

Blow yellowish or greenish mucusBlow clear mucus

With this illness, do you have difficulty breathing through your nose?

YesNo

Do over-the-counter decongestants make you feel better?

YesNo

Do you….?

Smoke cigarettes or other tobacco productsHave allergic rhinitisHave asthmaNone apply

Have you had the following?

No improvement, despite being on antibiotics for 3 days for this sinus infection.Feel like the sinus infection is coming back, though you have just finished antibiotics within the past 2 weeksAntibiotic use in the past month to treat something unrelated to a sinus infectionSinus symptoms that have lasted longer than 4 weeks4 or more sinus infections over the past yearRecent facial trauma or surgeryRecent hospitalization over the past weekNone apply

Do you have any of the following symptoms?

I see a lot of swelling or redness of the cheek(s) or the faceI see a lot of swelling / redness around the eye(s).Unable to open the eye(s)Uncontrollable shivering or shaking due to chillsProblems with vision, including double vision or difficulty focusingSevere headacheConfusionDifficulty breathing (not related to nasal congestion), shortness of breath, or wheezingChest painSevere neck pain and lights or sound bother youDizzinessProducing low amounts of urineSevere sore throat. Can't swallow my saliva. Can't eat or drinkVomitingNone apply

Are you allergic to any medicines? Milk protein? Aspirin, NSAIDs, or phenylalanine?

YesNo

Do you take other medication(s) or have any other medical conditions?

Include vitamins, herbs, and over-the-counter products, like pain relievers and sleep aids and WHY you are taking them.

YesNo

Do you have any of these conditions?

BreastfeedingPregnantDiabetesTendon problems (tendonitis) resulting from taking antibiotics in the pastJoint problems including rheumatoid arthritisHIVProblems with my immune system or taking immunosuppressive medicationHave or recently had mononucleosis (fatigue, swollen tonsils, sore throat, fever)Kidney problems including kidney stonesLiver problemsGlucose-6-phosphate dehydrogenase (G6PD) deficiencyHeart problemsKidney, heart, or lung transplantMyasthenia gravisNeurologic condition that causes seizures such as epilepsy ('fits')Anemia due to folate deficiencyUncontrolled hypothyroidismDrug-induced immune thrombocytopenia (low platelets) due to trimethoprim or sulfa drugsA malabsorption syndromePorphyriaNone apply

Anything else you would like us to know?

How would you like to pay?

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Personal Details

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First Name: Last Name:
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After you submit your request, a licensed medical provider will review your information. You will be notified by email/contact number when that provider has reviewed your request and, if appropriate, made care recommendations.