Patient First Name *

Last Name *

State you reside in *

Email Address *

Date of Birth *

Age *

How would you rate the overall humidity level in the area where you intend to use a humidifier? *  
Very humid   
Humid   
Dry   
Very dry   

Do you often experience dry or irritated eyes? *  
Never   
Rarely   
Sometimes   
Often   

Do you experience frequent nosebleeds? *  
Never   
Rarely   
Sometimes   
Often   

Do you often wake up with congestion or a stuffy nose? *  
Never   
Rarely   
Sometimes   
Often   

Do you have sinus congestion or frequent sinus infections? *  
No   
Yes   

Do you often have a sore throat or dry throat, especially in the morning? *  
Never   
Rarely   
Sometimes   
Often   

Do you have any respiratory conditions such as asthma or allergies? *  
No   
Yes, I have asthma and/or allergies   

How would you describe the dryness of your skin? *  
Not dry   
Slightly dry   
Moderately dry   
Very dry   

Has a healthcare professional ever recommended increasing the humidity in your home for medical reasons? *  
No   
Yes   

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