Taste and Smell Disorders
Respondent sequence number
Had problem with smell past 12 months?
Had change ability to smell since age 25
Smells bother you, but not others
Had phantom odor?
When noticed change in ability to smell
Frequency of problem w/ ability to smell
Had problem with taste past 12 months?
Ability to Taste Salt
Ability to Taste Sourness
Ability to Taste Sweetness
Ability to Taste Bitterness
Change in ability to taste food flavors?
Persistent taste in mouth past 12 months
Taste in mouth, Sweet
Taste in mouth, Sour
Taste in mouth, Salty
Taste in mouth, Bitter
Taste in mouth, Metalic
Taste in mouth, Burning or Tingling
Taste in mouth, Bad or Foul
Taste in mouth, Something else
When noticed change in ability to taste
Discussed T/S problem with Dr.?
When T/S problem last discussed with Dr.
Treatment for T/S problem last 12 months
T/S problem interferes with daily life?
Persistent cold/flu last 12 months?
Had persistent dry mouth in past 12 mth
Frequent nasal congestion in past 12 mth
Ever had Wisdom Teeth Removed
Ever had Tonsils Removed
Head Injury/Loss of counsciousness
Broke Nose/Serious Injury to Face/Skull
Ever had two or more sinus infections