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Patient Information
Appendix 3: Nasal Obstruction and Septoplasty
Effectiveness Scale
NOSE SCALE ADMINISTRATION
1. Have patient complete the questionnaire as indicated by circling the response closest
to describing their current symptoms.
2. Sum the answers the patient circles and multiply by 20 to base the scale out of a
possible score of 100 for analysis.
Physician AAO-HNS# Patient ID Date:
To the Patient: Please help us to better understand the impact of nasal
obstruction on your quality of life by completing the following survey.
ank You!
Over the past ONE month, how much of a problem were the following
conditions for you?
Please circle the most correct response.
Not a
Problem
Very Mild
Problem
Moderate
problem
Fairly Bad
Problem
Severe
problem
Nasal congestion or
stuffiness
0 1 2 3 4
Nasal blockage or
obstruction
0 1 2 3 4
Trouble breathing
through my nose
0 1 2 3 4
Trouble sleeping 0 1 2 3 4
Unable to get enough
air through my nose
during exercise or
exertion
0 1 2 3 4
From: Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and
validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck
Surg 2004;130:157-63.
