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Copyright 2013 Memorial Sloan-Kettering Cancer Center, New York, USA. All rights reserved.
| Not at all | A little | Moderately | Extremely | |
| a. Did you experience any difficulty in breathing through your nose? | 1 | 2 | 3 | 4 |
| b. Did you experience any tenderness (e.g., when wearing sunglasses)? | 1 | 2 | 3 | 4 |
| c. Did you experience a swollen or thick-looking skin of the nose? | 1 | 2 | 3 | 4 |
| d. Did you experience any unnatural appearing bumps or hollows on your nose? | 1 | 2 | 3 | 4 |
