| Not a Problem | Mild Problem | Moderate Problem | Fairly Bad Problem | Severe Problem | |
| 1. Nasal congestion or stuffiness | 0 | 1 | 2 | 3 | 4 |
| 2. Nasal blockage or obstruction | 0 | 1 | 2 | 3 | 4 |
| 3. Trouble breathing through my nose | 0 | 1 | 2 | 3 | 4 |
| 4. Trouble sleeping | 0 | 1 | 2 | 3 | 4 |
| 5. Unable to get enough air through my nose during exercise or exertion | 0 | 1 | 2 | 3 | 4 |