LAMPIRAN 4 Standardized questionnaire proposed for patient with chronic nasal symptom, * some question are taken or adapted from the ISAAC and ERCHS standardized questionnaire. Research for allergic rhinitis 1. In the past months,have you had a problem with sneezing or runny or blocked nose when you have not had a cold or the flu? 2. If yes: in the past 12 months, has this nose problem been accompanied by itchy,watery eyes? 3. Do you think that trigger factors provoke or increase your nose problem? If yes: what are they?...... 4. Have you ever had fever, asthma or skin allergy?..... 5. Has a member of your family ever had asthma, or skin or nasal allergy?..... Determine severity for classification 1. In the past 12 months ,how many timeshave these symptoms accured? Less than days a week or less than 4 week in the year? More than 4 days a week and for more than 4 weeks in the year? 2. In the past 12 months, have these nose problems be accompanied by sleep disturbance? 3. In the past 12 months,how much has this problem interfered with your daily activities, and/or sport? Sleep disturb ance Daily activit ies School, and or work Leisure Sport Not at all A little
LAMPIRAN 4Standardized questionnaire proposed for patient with
chronic nasal symptom, * some question are taken or adapted from
the ISAAC and ERCHS standardized questionnaire.Research for
allergic rhinitis1. In the past months,have you had a problem with
sneezing or runny or blocked nose when you have not had a cold or
the flu?2. If yes: in the past 12 months, has this nose problem
been accompanied by itchy,watery eyes?3. Do you think that trigger
factors provoke or increase your nose problem? If yes: what are
they?......4. Have you ever had fever, asthma or skin
allergy?.....5. Has a member of your family ever had asthma, or
skin or nasal allergy?.....Determine severity for classification1.
In the past 12 months ,how many timeshave these symptoms accured?
Less than days a week or less than 4 week in the year?More than 4
days a week and for more than 4 weeks in the year?2. In the past 12
months, have these nose problems be accompanied by sleep
disturbance? 3. In the past 12 months,how much has this problem
interfered with your daily activities, and/or sport?Sleep
disturbanceDaily activitiesSchool,and or workLeisureSport
Not at all
A little
A moderate amount
A lot
Identification of seasonal and occupational allergic rhinitis1.
Do you experience these symptoms every year only during a
particular season and always during the same season?2. Do you
experience these symptoms mainly during the working day?Do they
disappear during the weekend and holidays?3. Do you experience
these symptoms after the ingestion of aspirin or other pain-killing
tablets?
