Anosmia/loss of smell questionnaire

ANOSMIA/LOSS OF SMELL QUESTIONNAIRE

Name:_______________________________ Date of Onset:____________ Todays Date_____________

Tick All That Apply;

Loss Of Smell Loss Of Taste My Symptoms Began

 Complete  Cannot taste sweet  After a cold or flu

 Partial  Cannot taste bitter  After a head injury

 Sudden  Cannot taste sour  After change in medication

 Gradual  Distorted sense of taste  After environmental exposure  Other

Other Symptoms

 Runny nose  Burning mouth

 Post nasal drip  Dry mouth

 Difficulty breathing through nose  Dry eyes

 Mouth breathing  Frequent yeast infections

 Burning tongue  Migraine headaches

Your Medical History

 Environmental allergies  Sjogren’s Syndrome  Hysterectomy/ovarian removal

 Nasal polyps  Dental problems  Post menopause

 Previous nose or sinus surgery  Dentures

 Previous ear surgery  Recent mouth, throat or oral surgery

 Previous brain surgery  Psychiatric problems

 Liver disease  Depression

 Glandular problems  Previous chemotherapy

 Thyroid problems  Tobacco use

 Diabetes  Vitamin or mineral deficiency

Please describe any tumour or cancers you have had or currently have

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Please describe any neurologic problems you have had or currently have

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Mouthwash you use and how long you have been using it__________________________________________

Toothpaste you use and how long you have been using it__________________________________________

Any other information about your condition

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