Penn Medicine Penn Medicine Hospital of the University of Pennsylvania Smell and Taste Center Department of Otorhinolaryngology Please read carefully through the instructions below

~ Penn Medicine Hospital of the University of Pennsylvania Smell and Taste Center

Department of Otorhinolaryngology

Please read carefully through the instructions below. Richard L. Doty, Ph.D. Professor and Director

Please mail packet back by I I 2013

Appointment Reminder

You have been scheduled for an appointment at the Smell and Taste Center for an evaluation and treatment recommendation if there are any available for your smell and/or taste disorder.

Appointment Date: I I 2013 at 8:00 AM. Please keep in mind that this is an 8 hour appointment!

Please make every attempt to keep this appointment and let us know if for any reason you can't.

The Smell and Taste Center is located in The Hospital of University of Penn, at 3400 Spruce Street, 5 Ravdin Building, Phila, PA 19104.

Make envelope Attention to: Gerry Brennan.

1. All payments if any are to be paid by Check or Cash. 2. We require you to get only a prescription from a doctor that recommended you

visit us, if your insurance requires a referral please make sure you obtain one. If you would like to see an ENT here at UPenn after your visit with the Smell and Taste Center, please call 215-662-2778 to set up an appointment.

3. We don't not need any films, please only send copies of WRITTEN reports. 4. Please DO NOT staple any pages, nor separate and/or remove pages, we will

do that for you. 5. Make sure you return all filled out and signed paper work back 2 weeks prior to

your appointment. We suggest you do not send by regular mail (all regular mail take 7 to 10 business days for receipt), if you do please make a copy and bring the copies with you. We prefer you to send packet back via UPS or Fed ex.

6. Please bring a lunch!!! There is no refrigeration available and you will not be permitted to leave our waiting are to go get something, if you do it will prolong your testing.

7. If you bring family or friends with you, please note that only you and the tester will be permitted in testing areas. All visitors will be escorted to another waiting area.

If you should have any questions about this packet please feel fee to call Gerry Brennan at the center at 215-662-2797 Monday thru Friday, 9 am to 1 pm.

5 Ravdin 13400 Spruce Street I Philadelphia, PA 19104-42831 Phone: 215.662.6580 I Fax: 215.349.5266

NIVERSITY OF ENNSYLVANIA EALTH SYSTEM

PATIENT REGISTRATION QUESTIONNAIRE

Update D New D

In order to keep your records up to date, please answer the following questions on both sides of the form.

LOCATION PATIENT IDENTIFICATION NUMBER/MAN TEMPORARY ACCT. NUMBER VERIFIED BY/DATE

NAME OF PATIENT PATIENT ADDRESS

LAST FIRST MIDDLE FIRST LINE OF ADDRESS

SOCIAL SECURITY NUMBER

DATE OF BIRTH SEX: M F

EMERGENCY CONTACT ( )

AREA CODE EMERGENCY CONTACT TELEPHONE

FATHER'S NAME: _____ _ MOTHER'S NAME: _____ _

MAIDEN NAME: _____ _

RACE:* Arab: __ _ Asian : __ _ Black: __ _

Caucasian: Hispanic:__ Indian: __ _ Other: ____ _

MARITAL STATUS:* Married Single Divorced Widowed Separated __ Other __ _

*It is not mandatory to answer this question. However for statistical purposes, your answers would be appreciated.

GUARANTOR INFO (IF DIFFERENT THAN PATIENT)

LAST FIRST

SOCIAL SECURITY NUMBER

DATE OF BIRTH

FIRST LINE OF ADDRESS

SECOND LINE OF ADDRESS

CITY STATE

RELATIONSHIP TO GUARANTOR ( )

AREA CODE

EMPLOYER NAME



CITY (

STATE

SEX: M F

AREA CODE TELEPHONE

135680

ZIP

ZIP

MIDDLE


CITY (

STATE ZIP

AREA CODE HOME TELEPHONE ( )

AREA CODE DAY TELEPHONE

EMAIL ADDRESS

PATIENT EMPLOYMENT INFORMATION

EMPLOYER NAME



CITY (

AREA CODE

OCCUPATION

STATE

TELEPHONE

PRIMARY CARE/FAMILY PHYSICIAN

NAME



CITY (

AREA CODE

COMMENTS:

STATE

TELEPHONE

ZIP

MD

ZIP

DO

AEL 112001

UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM PATIENT REGISTRATION QUESTIONNAIRE

PATIENT NAME PATIENT IDENTIFICATION NUMBERJMRN

PRIMARY INSURANCE (please"./" the appropriate box below) SECONDARY INSURANCE (please"./" the appropriate box below)

BC/BS CJ

Commercial

NAME OF INSURANCE CO.



CITY STATE

CERTIFICATE NUMBER

GROUP NUMBER

I l HMO/PPO

ZIP

D POS

n BC/BS

CJ Commercial

NAME OF INSURANCE CO.



CITY STATE

CERTIFICATE NUMBER

GROUP NUMBER

D HMO/PPO

ZIP

[j

POS

PLAN NUMBER MEDICARE PLAN? Y or N PLAN NUMBER MEDICARE PLAN? Y or N

EFFECTIVE DATE EXPIRATION DATE ( )

AREA CODE TELEPHONE

SUBSCRIBER NAME (IF DIFFERENT)

RELATIONSHIP TO SUBSCRIBER

SUBSCRIBER'S BIRTHDAY

SUBSCRIBER'S SEX: M or F

MEDICAL ASSISTANCE

RECIPIENT NUMBER

CARD ISSUE NUMBER

MANAGED CARE/MEDICAL ASSISTANCE PLAN NAME:

IDENTIFICATION NUMBER

MEDICARE Please Answer Questions Below

Health Insurance

SOCIAL SECURITY ACT

NAME OF BENEFICIARY

MEDICARE CLAIM NUMBER SEX

IS ENTITLED TO

HOSPITAL

MEDICAL

EFFECTIVE DATE

(PART A)

(PART B)

EFFECTIVE DATE EXPIRATION DATE ( )

AREA CODE TELEPHONE

SUBSCRIBER NAME (IF DIFFERENT)

RELATIONSHIP TO SUBSCRIBER

SUBSCRIBER'S BIRTHDAY

SUBSCRIBER'S SEX: M or F

WORKER'S COMPENSATION/AUTO ACCIDENT INFO (Please Circle Either Worker 's Compensation or Auto Accident)

INSURANCE CARRIER'S NAME



CITY (

STATE

AREA CODE TELEPHONE

DATE OF INJURY I ACCIDENT

CLAIM NUMBER/POLICY NUMBER MULTIPLE CLAIMS? YorN

ZIP

Medicare Questions (Please Circle Y or N)

Are you or your spouse employed? Do you or your spouse have other insurance? Are you disabled or have end stage renal disease? Is this illness or injury the result of an auto accident? Did this illness or injury occur at work? Has treatment been authorized by the V.A.? Are you covered under the Black Lung Program? Is there Medigap coverage secondary to Medicare? Is there employer supplemental insurance secondary to Medicare? Is there insurance coverage primary to Medicare?

YorN YorN YorN YorN YorN YorN YorN YorN YorN YorN

~ Penn Medicine Hospital of the University ofPennsylvania Smell and Taste Center

Department of Otorhinolaryngology

AOB -Assignment of Benefits

Assignment of Benefits: I am receiving medical care and services by the physicians ofthe Clinical Practices of the University of Pennsylvania and/or Clinical Care Associates (System Provider(s)). In exchange for that care and treatment, I give and assign to one or more of the System Providers, as appropriate, the right to receive payment directly for all insurance and other health benefits to which I am entitled, and/or which may be payable on my behalf. I understand that this is called "assignment of benefits: and that the System Providers may be called my "assignees." This assignment shall not be for more than the physicians charges. I understand that I may be required to pay for charges that others do not pay on my behalf under this assignment. I agree that the System Providers can sue anyone in their own names as my assignee and get payment for the charges resulting from my medical care. This amount may include charges on the bill for my care and layer' s fees resulting from collection efforts.

Medicare Benefits: I request that payment of Medicare benefits be made on my behalf to one or more of the System Providers for any medical services, care or treatment any of them may provide to me. I authorize the System Providers and their agents to give the Centers for Medicare and Medicaid Services and its agents any medical information about me (or the person I signed for) needed to determine these benefits payable for related services. I have provided accurate information about Medicare secondary payers.

Patient

Patient' s spouse, parent, child or other responsible Party individually and as agent for patient

Date

Relationship to Patient

5 Ravdin I 3400 Spruce Street I Philadelphia, PA 19104-4283 I Phone: 215.662.6580 I Fax: 215.349.5266

-------------- ----- --

~ Penn Medicine Hospital of the University of Pennsylvania

HIPPA

Signature of Patl.ent o:-

Legally Auchorized Kepresentat~ve

Pr1nc.ed Name of

Legally Authorl.zed Representatl.ve

GENERAL CONSENT TO

Cate:

Smell and Taste Center Department of Otorhinolaryngology

Legal RelationshJ.p to Patient

(e.g., Fare~t or guard~an

USE AND DISCLOSE PROTECTED HEALTH lNFORNATlCN

This is a consent forr.t. It asks you tc permit us t.o use and dlsclose intornat1or:. about. your hea:th in

;.;.eeping with both state and Federal law. Thls J.nformacion lS called •protected healc!': intormation. u It lS ar.y

i:normaticn we receive or create ~!'!at identifies (or cou:o iC.ent.i:y, you and deals '"'i::h yot:.::. physi..:a::.. or ;r;e?::.a!

:ealth, any health c~re we provide you and/o~ pa)ment ior such hr~ltt. ca~e.

By signing th~s form, you are conser.:.lr:g to our use anC dlsCl,.Jsure o: your prctecced health lnformaclc- .u:

~rder co carry out r.rea>:: .em:, paynent or healt.h care ope:::-at::....;!:S, a:;; fu.rt.l:er expla~:'led in Cl:.r ••Notice o~ Pr1vocy

~rac:.1ces" (the "No:..~ce").

By s_gnlng thi.~ forrr .. ycu also acknowledge that you have recci·:ed our Not.lce Th1s Nct.1ce descl.-.lbes in

letall how we might use or dl.sclose your protected health information. The Not1ce also dlscus=es your rights and

ur duties with rest'ect to your protected health information. You have the right to revie., the N0tice before

ilgning thls conser.t

Eefort:: releasing an_,: informat.icn about your treatment for dn.:.g abuse, alcohol abuse or mental illness, ar.d

I!V or A.,.DS, othe.~- than as perm.ltted or required by law, we will .1sk: you to s:.gn a separ~r.e consent form.

You also have the ri.ght to revoke this consent:, in writing, except w'l'1ere we have previously taken action lr..

eliance on youz.· pri<..•r C011SenL.

I( you refuse ~u s~gr. this consen~ form, we will not be able to ~~ea~ you.

5 Ravdin 13400 Spruce Street I Philadelphia, PA 19104-4283 I Phone: 215.662.6580 I Fax: 215.349.5266

~ Penn Medicine Hospital of the University of Pennsylvania

Payment Agreement

Smell and Taste Center Department of Otorhinolaryngology

For Independence Blue Cross and Blue Shield Insurance Subscribers University of Pennsylvania Health System: The Smell and Taste Center

Welcome to the Hospital ofthe University of Pennsylvania. We appreciate your confidence in choosing our hospital for your health care needs.

Unlike most insurance carriers, Independence Blue Cross and Blue Shield (e.g. Personal Choice, Keystone East, Keystone Mercy, Health Partners, Americhoice) will not cover the total charges for outpatient diagnostic testing (procedure codes: 92512, 92700, 95900 and diagnostic code: 781.1) at the Smell and Taste Center. In response to their policy, the Smell and Taste Center requires a non-refundable $450.00 payment to be made before any services are provided. If the insurance company does not pay our estimated charges, the payment will not be refunded. The $450.00 Payment will be considered payment in full and charges will be adjusted to reflect $450.00 and not the full cost of testing. Therefore you will not be charged more then $450.00 for this appointment, unless you are involved in a litigation case.

My signature indicates that I accept Payment Agreement.

All patient must sign below regardless of you health insurance coverage.

PATIENT SIGNATURE: ___ ______ DATE: _____ _

5 Ravdin I 3400 Spruce Street I Philadelphia, PA 19104-4283 I Phone: 215.662.6580 I Fax: 215.349.5266

For a Referral Below is a list of procedures that will be preformed on the day of clinic,

and that you may need when speaking with your PRIMRA Y CARE PHYSCIAN.

This ONLY applies to Aetna, Cigna, and Blue Cross/Blue Sheild patients Medicare patients do not need Referrals

(Diagnosis code: 781.1) (Referring Doctor Natasha Mirza NPI # 1487767422) (Tax ID # 232706750)

PROCEDURE CODE

DESCRIPTION

92700D Intake/Exit Interview and History Questionnaire: The review of

$ Olfactory and Taste History and 350 item intake Questionnaire

92700F Bilateral Smell Threshold Test: Bilateral testing of smell acuity

$ using phenyl ethyl alcohol.

Smell ID Test (UPSIT): The University of Pennsylvania Smell

92700E Identification test. This bilateral test is a microencapsulated olfactory

$ test that is routinely administered by many physicians throughout the world.

Smell Threshold Unilateral Testing: A detection threshold 92700H measurement of the smell acuity within each naris using the odorant $

phenyl ethyl alcohol.

Taste-Suprathreshold Test: A test of the patient's whole mouth

927001 taste ability that uses various concentrations of sweet, sour, bitter and $ salty stimuli to establish suprathreshold determinates of taste rl".of'nnf't;An

Taste Quadrant Test: A test to ascertain whether localized deficits 92700J are present on regions of the tongue subserved by the left and right $

chords tympani and the left and right glossopharyngeal nerves.

92512A Acoustic Rhinometry: A sonar-like procedure for determining the

$ volume of the nasal chamber.

92700K Nasal Air Flow: An anterior rhinomanometric procedure for

$ determining the resistance of the airflow within each side of the nose.

Electrogustometry: A threshold measurement of the lowest electric 95900A current (in microamperes) detectable on each side of the tongue. This $

test provides a means of assessing basal nerve sensitivity.

92700L Smell Suprathreshold Odor Memory Test: A test designed to

$ assess central components of smell dysfunction.

~

'

COST

309.00

309.00

180.00

290.00

335.00

412.00

258.00

290.00

290.00

258.00

"'.,.:H.UU

BDI® II •• I Date:

Name: Marital Status: _____ Age: __ _ Sex:

Occupation: Education:

Instructions: This questionnaire consists of 21 groups of statements. Please read each group of statements carefully, and then pick out the one statement in each group that best describes the way you have been feeling during the past two weeks, including today. Circle the number beside the statement you have picked. If several statements in the group seem to apply equally well, circle the highest number for that group. Be sure that you do not choose more than one statement for any group, including Item 16 (Changes in Sleeping Pattern) or Item 18 (Changes in Appetite).

1. Sadness 0 I do not feel sad.

2

3

I feel sad much of the time.

I am sad all the time.

I am so sad or unhappy that I can't stand it.

2. Pessimism 0 I am not discouraged about my future.

1

2

3

I feel more discouraged about my future than I used to be.

I do not expect things to work out for me.

I feel my future is hopeless and will only get worse.

3. Past Failure 0 I do not feel like a failure.

1 I have failed more than I should have.

2 As I look back, I see a lot of failures.

3 I feel I am a total failure as a person.

4. Loss of Pleasure 0 I get as much pleasure as I ever did from the

things I enjoy.

1 I don't enjoy things as much as I used to.

2 I get very little pleasure from the things I used to enjoy.

3 I can't get any pleasure from the things I used to enjoy.

5. Guilty Feelings 0 I don't feel particularly guilty.

I feel guilty over many things I have done or should have done.

2 I feel quite guilty most of the time.

3 I feel guilty all of the time.

6. Punishment Feelings 0 I don't feel I am being punished.

1 I feel I may be punished.

2

3

I expect to be punished.

I feel I am being punished.

7. Self-Dislike 0 I feel the same about myself as ever.

1

2

3

I have lost confidence in myself.

I am disappointed in myself.

I dislike myself.

8. Self-Criticalness 0 I don't criticize or blame myself more than usual.

1 I am more critical of myself than I used to be.

2 I criticize myself for all of my faults.

3 I blame myself for everything bad that happens.

9. Suicidal Thoughts or Wishes 0 I don't have any thoughts of killing myself.

1 I have thoughts of killing myself, but I would not carry them out.

2 I would like to kill myself.

3 I would kill myself if I had the chance.

10. Crying 0 I don't cry anymore than I used to.

1 I cry more than I used to.

2 I cry over every little thing.

3 I feel like crying, but I can't.

___ Subtotal Page 1

till\ THE PSYCHOLOGICAL CORPORATIOW W Harcourt Brace & Company ------ SAN ANTONIO -----Orlando • Boston • New York • Chicago • San Francisco • Atlanta • Dallas San Diego • Philadelphia • Austin • Fort Worth • Toronto • London • Sydney

Copyright © 1996 by Aaron T. Beck 0154018392 All rights reserved. Printed in the United States of America.

11. Agitation

0 I am no more restless or wound up than usual.

1 I feel more restless or wound up than usual.

2 I am so restless or agitated that it's hard to stay still.

3 I am so restless or agitated that I have to keep moving or doing something.

12. Loss of Interest 0

1

2

3

I have not lost interest in other people or activities.

I am less interested in other people or things than before.

I have lost most of my interest in other people or things.

It's hard to get interested in anything.

13. Indecisiveness 0 I make decisions about as well as ever.

I find it more difficult to make decisions than usual.

2 I have much greater difficulty in making decisions than I used to.

3 I have trouble making any decisions.

14. Worthlessness 0 I do not feel I am worthless.

I don't consider myself as worthwhile and useful as I used to.

2 I feel more worthless as compared to other people.

3 I feel utterly worthless.

15. Loss of Energy 0 I have as much energy as ever.

I have less energy than I used to have.

2 I don't have enough energy to do very much.

3 I don't have enough energy to do anything.

16. Changes in Sleeping Pattern 0 I have not experienced any change in my

sleeping pattern. 1a I sleep somewhat more than usual.

1b I sleep somewhat less than usual.

2a I sleep a lot more than usual.

2b I sleep a lot less than usual.

3a I sleep most of the day.

3b I wake up 1-2 hours early and can't get back to sleep.

NOTICE: This form is printed with both blue and black ink. If your copy does not appear this way, it has been photocopied in violation of copyright laws.

17. Irritability 0 I am no more irritable than usual.

1 I am more irritable than usual.

2 I am much more irritable than usual.

3 I am irritable all the time.

18. Changes in Appetite 0 I have not experienced any change in my

appetite.

1a My appetite is somewhat less than usual.

1b My appetite is somewhat greater than usual.

2a My appetite is much less than before.

2b My appetite is much greater than usual. 3a I have no appetite at all.

3b I crave food all the time.

19. Concentration Difficulty 0 I can concentrate as well as ever.

1 I can't concentrate as well as usual.

2 It's hard to keep my mind on anything for very long.

3 I find I can't concentrate on anything.

20. Tiredness or Fatigue 0 I am no more tired or fatigued than usual.

1 I get more tired or fatigued more easily than usual.

2 I am too tired or fatigued to do a lot of the things I used to do.

3 I am too tired or fatigued to do most of the things I used to do.

21. Loss of Interest in Sex 0 I have not noticed any recent change in my

interest in sex.

1 I am less interested in sex than I used to be.

2 I am much less interested in sex now.

3 I have lost interest in sex completely.

___ Subtotal Page 2

___ Subtotal Page 1

Total Score

w 0 (.)

Ill <{

0 C')

0> N co N ,.... N CD N l() N "'¢ N C') N N N

Dl'!® IJi 11-----------------------------------NAME DATE Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by each symptom during the PAST WEEK, INCLUDING TODAY, by placing an X in the corresponding space in the column next to each symptom.

1. Numbness or tingling.

2. Feeling hot. I I I I 3. Wobbliness in legs. I I I I 4. Unable to relax.

5. Fear of the worst happening.

6. Dizzy or lightheaded.

7. Heart pounding or racing.

8. Unsteady.

9 . Terrified.

10. Nervous.

11. Feelings of choking. I I 12. Hands trembling. I I

13. Shaky.

14. Fear of losing control.

15. Difficulty breathing.

16. Fear of dying.

17. Scared.

18. Indigestion or discomfort in abdomen.

19. Faint.

20. Face flushed.

21. Sweating (not due to heat) .

I I I I I I

1\ffiTHE PSYCHOLOGICAL CORPORATION" W Harcourt Brace & Company ----- SAN ANTONIO----Orlando. Bosron · New 'fork • Ch1cago • San FranciSCO· Altanta • O'.illa~>

San Ou:go • Phihtdc:lph1a • Austin • ~ort Worth • Torooto • London

I I I I I I I I I I I I

· r · b roduced or transmitted in any form or by any means, electronic or mechamcal. Copyright© 1990, 1987 by Aaron T. Beck. All rights reserved.dNo tart ~f thi~ ~~~~~~~ p~~~IS~I~~in writing from the publisher. BAI is a registered trademark of The Psychological including photocopy, recording, or any Information storage an re neva sys e ' 40 41 42 43 44 45 ABc DE 0154018422 Corporation. Printed in the United States of Amenca.

SMELL AND TASTE CENTER Handedness inventory

Today's Date:------------

Name: ____ ____ _____ ___ Age: ___ ._

University of Pennsylvania Medical Center

3400 Spruce Street, Philadelphia, PA 19104-4283

Sex: ____ Male ____ Female

Ethnicity: __ American Indian _ _ Asian/Pacific __ Black __ Hispanic __ White __ Other

Indicate hand preference

1. To write a letter legibly

2. To throw a ball to hit a target

3. To play a game requiring the use of a racquet

4. At the top of a broom to sweep dust from the floor

5. At the top of a shovel to move sand

6. To hold a match when striking it

7. To hold scissors to cut paper

8. To hold tread to guide through the eye of a needle

9. To deal playing cards

10. To hammer a nail into wood

11 . To hold a toothbrush while cleaning teeth

12. To unscrew the lid of a Jar

Are/were either of your (natural) parents left-handed?

How Many siblings of each sex do/did you have?

Always Left Usually Left No preference Usually Right Always Right

Yes If yes which?

Male

Which eye do you use when using only one (e.g. telescope, keyhole)?

No

Female

Left

No

__ Right

Have you ever suffered any severe head trauma? __ Yes

Staff Use: ______ _

(Adapted from : Briggs, G.G. and Nevers, RD. 1975 Cortex, 11 :232

Smell and Taste Center Questionnaire

SMELL AND TASTE CENTER PATIENT CONSENT FORM

Hospital ofthe University of Pennsylvania, 3400 Spruce Street, 5 Ravdin Pavilion, Philadelphia, PA 19104-4283

The University of Pennsylvania Smell and Taste Center, an institution founded by the National Institutes of Health, is devoted to evaluating, treating, and better understanding of the senses of smell and taste in health and disease. The Center is an integral part of the School of Medicine and is closely affiliated with a number of medical centers in the Philadelphia area.

We seek your permission to obtain and keep on file all information regarding your medical history, smell and taste evaluations, and other pertinent data of potential medical and scientific importance to your care and the goals of the Center. We also seek your permission to utilize this information for medical and scientific purposes and to have the option to contact you in the future should any new information or studies become available that may be related to your case. Your information will be kept confidential and will only be available to appropriate professionals for medical and scientific purposes. Your information will be safe guarded according to Health Insurance Portability and Accountability Act (HIP AA) guidelines.

I, (print full name), have read the above and give permission to have information related to my smell and taste functioning, as well as other medical history and questionnaire data deemed appropriate for the University of Pennsylvania Smell and Taste Center registry, to be obtained, stored and analyzed for scientific and medical purposes. I understand that this information will be kept confidential and will only be available to appropriate professionals for medical, scientific, and teaching purposes. I also give permission to be contacted in the future should any studies or other information become available related to my chemosensory condition.

I I Signature of Patient (or Guardian) Date

I I

Signature ofUniversity of Pennsylvania Smell and Taste Center Staff Date


SECTION I -GENERAL INFORMATION

Instructions: The following information is required so that we may better understand your taste or smell problem and similar problems in other people. We request that you complete all items to the best of your ability.

1. Name: -------,.,-----,--- -------=--------...,...,...,....,.,...-,- 2. Today' s Date: __ / __ / __ (Last) (First) (Middle) (Mo.) (Day) (Year)

3. Home Telephone:('--_ __,) ______ _ 4. Work Telephone:<~_,) _ __ ext.

5. Mailing Address: ________________________ _ (Street) (city)

6. Date of Birth: I I 7.Age: __ _ (Mo.) (Day) (Year)

(state)

8. Sex:

(zip)

O Male

(E-mail)

0 Female

9. MRN# (OFFICE USE ONLY).: ______ _ 10. Height: __ _ 11. Weight: __ _

12. Ethnicity: 0 African American 0 Caucasian 0 Native American

0 Asian/Pacific Islander 0 Hispanic American 0 Other (specify) ____ _

13. Highest Level of Education: 0 No formal schooling

14. Occupation Classification:

0 Grade school (K-5) 0 Middle school (6-8) 0 High school (9-11) 0 High school graduate (or GED) 0 Some college 0 College graduate 0 Post-graduate 0 Technical school (specify) __________ _ 0 Other (specify) _____________ _

0 Agricultural Worker 0 Biomedical Worker

0 Industrial Worker

0 Business/Financial 0 Chemical Industry Worker 0 Clerical Worker

0 Legal Worker 0 Manager 0 Military 0 Retired

0 Construction 0 Craftsman

0 Sales/Service Industry

0 Engineering 0 Home Economist

0 Student (Full time college) 0 Student (High School) 0 Teacher

0 Professional (specify) ___________ _ 0 Other (specify) _____________ _

0 Unemployed

15. Is English your primary language? 0 Yes O No If No: What is?

2


16. Who referred you to this clinic? 0 General Practitioner 0 Neurologist 0 Lawyer

0 Dentist 0 Ear, Nose & Throat Specialist 0 Other (specify) ____ _

Fill out all relevant information for the person referring you to this clinic:

Please be advised that the results of the evaluation and/or consultation done by the Smell and Taste Center will be shared with the providers you list in this section for treatment purposes.

Name: --------------------------------------------------------------If doctor: Degree (e.g., MD, DO, Ph.D., DDS, etc.): ___________ _

Specialty or Practice N arne: ------------------------------------------Phone Number: : L___) __ -__

Mailing Address: -----:-::-:---:-:-------------....,....,-,--------,---,-,-----=::-:-:--(Street) (city) (state) (Zip)

17. List any doctors you have visited regarding your smell and/or taste problem in addition to the referring doctor.

Name: -------------------------------------Ifdoctor: Degree (e.g., MD, DO, Ph.D., DDS, etc.): ___________ _

Specialty or Practice Name: --------------------------------Phone Number: : L___) __ -__

Mailing Address: ------=----,-------------------....,..,..-,-------......,--,-----=::-:-:--(Street) (city) (state) (Zip)

Name: If doctor: Degree (e.g., MD, DO, Ph.D., DDS, etc.): Specialty or Practice Name: Phone Number: : L___) __ -__ Mailing Address:

(Street) (city) (state) (Zip)

Name: ----------------------------------If doctor: Degree (e.g., MD, DO, Ph.D., DDS, etc.): ___________ _ Specialty or Practice Name: _________________________ __ Phone Number: : L___) __ -__

Mailing Address: -----=--,-------------------------(Street) (city) (state) (Zip)

18. Do you observe any religious, medical or personal dietary restrictions? 0 Yes 0 No If Yes: Explain: ____________________________ _

19. Do you have any physical or psychological conditions that are potentially related to specific foods or odors (e.g. allergies, fainting spells, etc.)? 0 Yes 0 No

If Yes: Explain: ___________________________ _

3


19b. Do you exercise? 0 Yes 0 No How many times per week: ___________ and how many minutes: ______ _ What type of exercise: ___________________________ _

If you run how far: _________ how man minutes: ________ _

Indoors outdoors both ----- ----- ------

20. How much of the following do you drink per week of:

Coffue cups Tea Fruit Juices 8-oz Beer Milk 8-oz Wine Soft Drinks 16-oz Liquor

___ cups 12-oz ---

___ glasses shots ---

21. Do you currently smoke? 0 Yes O No

If Yes:

If No:

At what age did you start smoking? If you quit and restarted, how many total years have you smoked? Do you inhale? 0 Yes 0 No Have you noticed any change in smell ability due to smoking? 0 Yes O No How much of each do you use per day: Cigarettes:

Cigars: Pipes:

Have you ever smoked? 0 Yes 0 No If Yes: At what age did you begin smoking?

___ packs each ---each ---

How much of each did you use per day: Cigarettes: ___ packs each Cigars: ---

Pipes: each ---At what age did you quit smoking? Did your smell ability change after you quit smoking? 0 Yes 0 No Explain: _________________ ___

21 A. Do you chew gum? 0 Yes O No

If Yes: How many do you chew per day: packs ___ sticks

What Brand: When Did you Begin: ____ _

22. Do you currently use smokeless tobacco (e.g., snuff, chew, etc.)? 0 Yes O No If Yes: How much do you use per day? pinches

23. Is there tobacco smoke in your immediate living and/or work environment (e.g., someone who lives with you smokes)? 0 Yes 0 No

If Yes: For how many hours/day are you exposed to the smoke? __ hrs/day How many months and/or years have you been exposed? __ mo. __ yrs.

4


23A. Do you receive an annual flu vaccination? D Yes D No If no, have you ever received a flu vaccination? D Yes D No

Ifyeswhen? ________________________________ _ If yes, for how many years have you be receiving a flu vaccination? __ years

What type of vaccination did you receive? D Injection D Nasal Inhalation

SECTION II - MEDICAL HISTORY

Instructions: Please answer each of the following questions. If answer is yes, check all boxes below that apply and state the years you had the problem. If a problem re-occurred during several different years, use a comma to separate (e.g.,1983,1989).

24. Do you have or have you ever had any nasal/sinus problems?

Check all that apply D Frequent or chronic sneezing or itchy nose D Prolonged abnormal nasal discharge D Frequent or chronic trouble breathing through the nose D Frequent or chronic post nasal drip D Sinus pain or headache D Sinus infection D Nasal polyps D Deviated septum of the nose D Frequent nosebleeds D Broken nose D Nasal allergy D Frequent colds D Other (specify) ____________ _

D Yes D No

25. Do you have or have you ever had any serious respiratory problems? D Yes D No

Check all that apply Years D Chronic coughing D Wheezing or asthma D Chronic or recurrent lung infections (e.g. bronchitis,

pneumonia) D Other (specify) ___________ _

26. Do you have or have you ever had any dental or mouth problems? D Yes D No

Check all that apply D Sensitive or sore tongue

5


0 Dry mouth 0 Trouble with wisdom teeth 0 Ulcer or sores 0 Trouble swallowing 0 Caps or crowns 0 Gum disease 0 Other (specify) ____________ _

27. On average, how often do you get sick? __ number of times per year

28. Do you have or have you ever had dentures?

Check all that apply

0 Partial dentures 0 Full dentures 0 Lower dentures 0 Upper dentures

0 Yes O No

29. Have you ever had any surgical operations pertaining to Ear, Nose, or Throat? 0 Yes 0 No

Check all that apply How many times? Date(s) Specific nature of operation

0 Deviated septum repair 0 Nasal polypectomy 0 Sinus surgery 0 Brain surgery 0 Mouth surgery 0 Wisdom tooth removal

If so, which teeth were removed? 0 Right Upper 0 Left Upper 0 Right Lower 0 Left Lower

If so, when were your wisdom teeth removed? 0 One year ago 0 Two to Five years ago 0 Five to Ten years ago 0 More than 1 0 years ago 0 Don't Remember

6


0 Other tooth extractions 0 Gum surgery 0 Tonsillectomy . 0 Laryngectomy 0 Ear surgery: 0 Other surgeries (specify) ___ _

30. Have you ever had any head or facial injuries?

Check all that apply 0 Head injury

Explain: _______________ _ 0 Facial injury

Explain: _______________ _ 0 Duration ofloss of consciousness due to injury:

0 less than 2 minutes

0 Yes ONo

0 between 2 minutes and 1 hour 0 between 1 hour and 1 day 0 between 1 day and 1 week 0 between 1 week and 1 month 0 greater than 1 month

0 Amnesia (memory loss of events surrounding injury): 0 Less than 12 hours 0 Between 12 hours and 24 hours 0 More than 24 hours

31. Have you ever been given general anesthesia?

How many times? __

32. Do you suffer from any allergies?


0 Medication allergies Specify:

0 Seasonal allergies

(e.g., pollen, grass, ragweed) Specify:

0 Yes O No

Type of reaction

7

0 Yes O No


0 Perennial allergies

(e.g., dust, molds, animals) Specify:

0 Food allergies

Specify: ______ _

0 Other allergies Specify: ______ _

33. Have you ever had any specialized radiographs of your head, neck, jaws, or sinuses? 0 Yes 0 No

Check all that apply 0 X-rays 0 Computer Tomography (CT) 0 Magnetic Resonance Imaging (MRI) 0 Single Photon Emission Computer Tomography (SPECT) 0 Positron Emission Topography (PET) 0 Functional Magnetic Source Imaging (FMSI)

34. Have you ever had prolonged exposure to any of the following?

Check all that apply 0 Acid fumes 0 Formaldehyde 0 Herbicides or pesticides 0 Industrial solvents or cleaning products 0 Metal dusts 0 Paint fumes 0 Wood dusts 0 Other (specify) _______ _

Amount of Exposure (hrs, days, months, or years)

8


35. Have you ever experienced any of the following conditions?


0 Alcohol abuse 0 Alzheimer's disease 0 Bell's palsy (facial nerve weakness or paralysis) 0 Cancer or tumor (specify) __________ _ 0 Cerebral Palsy 0 Cystic fibrosis 0 Depression 0 Diabetes mellitus 0 Drug abuse 0 Frequent ear aches 0 Gastroesophageal reflux disorder 0 Frequent heartburn or vomiting 0 Headaches 0 High blood pressure 0 Liver condition 0 Lupus 0 Multiple sclerosis 0 Neurosis 0 Vitamin or mineral deficiency 0 Parkinson's disease 0 Psychosis 0 Rheumatoid arthritis 0 Sarcoidosis 0 Schizophrenia 0 Seizures or epilepsy 0 Sjorgen's syndrome 0 Stroke 0 Thyroid problem 0 Other (specify) _____________ _

36. Has anyone in your family had a smell and/or taste problem? If Yes: Relationship (e.g., sibling, grandparent, etc.)

9

0 Yes D No Problem


37. Indicate below all medications (prescription or over the counter) you are currently taking or have taken within 5 years prior to your problem.

Instructions: Fill in the "Year began" and "Year Ended" for each medication, if you are still taking a medication, write 'on going' in the "Year Ended" blank. Check the "Onset" box if your problem began shortly after beginning to take the medicine.

Current Medications

Name Milligrams How often Start Ended Reason for use Onset

Past Medications

Name Milligrams How often Start Ended Reason for use Onset

Please list any over the counter Antacids you have taken

What brand How often How many How long

10


38. Please describe in your own words the nature of the problem you are seeking treatment for, and the way in which you feel these symptoms may have developed. Include all symptoms that you feel are related to the problem and indicate when each began and whether each symptom is constant or if it has changed since the problem started. Also, please indicate what treatment(s), if any, you have received for this problem and whether you feel they have been effective or not. Please include dates as closely as possible. Be concise but complete and accurate as possible. Please write legibly. Thank you.

39. Do you suffer, or have you ever suffered from any endocrine dysfunction, abnormality or change which brought you to the attention of a physician or other medical professional (for example, problems with the sex organs, the thyroid gland, the adrenal gland, puberty, fertility, change in life)? D Yes D No

If Yes: Explain: ________________________ _

40. Have you ever had an operation involving your sex organs (e.g. hysterectomy, castration, ovariectomy)? D Yes D No

II


If Yes: Explain: ________________________ _

Questions 41-50 are to be filled out by women only.

If you are male or postmenopausal please go to question 51.

41. Do you currently take oral contraceptives? 0 Yes 0 No If Yes: How long have you been taking them? __ days __ mo. __ yrs.

What brand are you currently using? ______________ _ Are the oral contraceptives being taken for reasons other than birth control? 0 Yes 0 No

If Yes: Explain: _____________________ _

42. Are you currently taking oral contraceptives, 0 Yes 0 No

Have you ever taken oral contraceptives? 0 Yes 0 No If Yes: How long ago did you take them? __ mo. __ yrs.

How long did you take them? mo. __ yrs. What brands did you use? __________________ _ Was there a particular medical or personal reason for discontinuing their use? 0 Yes 0 No

If Yes: Explain: _____________________ _

43. Have you ever kept a temperature chart or other count of your menstrual cycle? 0 Yes ONo

44. Is your menstrual cycle regular (i.e., does the period of bleeding start every 28 days, every 29 days, every 30 days, etc. without or rarely without fail?) 0 Yes 0 No

45. Approximately what day of your cycle is it today? (day 1 =first day of menstrual bleeding) __ (day) of __ (length of cycle)

46. How long, on average, does your period of menstrual bleeding last? __ days

4 7. Have you ever experienced any acute or partially disabling medical or psychological symptom as a result of the menstrual cycle or as a result of taking oral contraceptives? 0 Yes ONo If Yes: Explain: ________________________ _

48. Around the time of ovulation (i.e., mid-cycle or about day 14 in a regular 28 day

12


cycle, where 1 = first day of menstrual bleeding), do you ever notice intermittent cramping pains on one or both sides of the lower abdomen lasting for about a day (termed "Mittelschmerz")? D Yes D No If Yes: Explain: ___ ______________________ _

49. At what age did you experience your first period of menstrual bleeding? __

50. Have you noticed changes in your ability to smell or taste during the menstrual cycle? D Yes D No

If Yes: Was your ability increased during: D Menses D Mid-cycle D Pre-menstrual 0 None of these

Was your ability decreased during: D Menses D Midcycle D Premenstrually D None of these

SECTION Ill- SMELL AND NASAL INFORMATION

51. Check each of the following statements that apply to you now: 0 My sense of smell is distorted, that is things smell peculiar. D I experience a smell when nothing is there (phantom smell). D My sense of smell is heightened (hypersensitive). 0 My sense of smell is diminished (partial loss). D My sense of smell is absent (complete loss). D My main complaint is an abnormal body odor. D My sense of smell is normal. <- If you checked this box please go to question 98,

Section IV - Taste and Oral Information.

52. Is one or both sides of your nose obstructed? D Yes D No If Yes: Circle the number related to the amount of obstruction for each nostril :

Left side: Right side:

(no obstruction) 1 2 3 4 5 6 7 8 9 10 (complete obstruction) (no obstruction) 1 2 3 4 5 6 7 8 9 10 (complete obstruction)

53. Do you experience excessive nasal secretions or mucus? D Yes D No If Yes: Explain: __________ _____ _________ _

13


54. Do you experience dryness or crustiness in the nose? 0 Yes ONo If Yes: Explain: ________________________ _

55. Does your smell problem change over time? 0 Yes ONo If Yes:

Check all that apply 0 Before meals (specify which meals) 0 After meals (specify which meals) 0 Before going to sleep 0 After waking up 0 Certain time of the day (specify the time) 0 Other (specify exactly what and when)

Explain

56. Does your smell return to normal periodically? 0 Yes 0 No

57. Is your smell problem increased by anything? 0 Yes 0 No 0 Exercising 0 Certain foods or beverages (specify) ________ _ 0 When taking medication (specify) _________ _ 0 Other (specify) _______________ _ 0 Never increases

58. Is your smell problem decreased by anything? 0 Yes 0 No 0 Exercising 0 Certain foods or beverages (specify) ________ _ 0 When taking medication (specify) _________ _ 0 Other (specify) _______________ _

59. Do you sometimes perceive a smell or food flavor when you first encounter an item but find that the sensation disappears rapidly? 0 Yes 0 No

60. Does your smell problem interfere with eating? 0 Yes 0 No If Yes: Has it changed your appetite? 0 Yes 0 No

Have you suffered weight or appetite loss as a result of your smell problem? 0 Yes ONo

If Yes: How much weight loss? __ lbs. Explain: ____________________ _

If No: Have you experienced any other physical changes as a result ofyour smell problem? 0 Yes 0 No

If Yes: Explain: ________________ _

61. Does your smell problem interfere with your everyday functioning? 0 Yes 0 No If Yes: Explain: ________________________ _

14


62. Has your smell problem affected your psychological well-being? 0 Yes ONo If Yes: Explain: _ _ ______________________ _

63. Did your smell problem occur gradually over time? 0 Yes 0 No If Yes: How long did it take for you to lose your sense of smell?

0 Less than 1 month 0 Between 1 and 6 months 0 Between 6 months and 1 year 0 Between 1 and 5 years 0 Longer than 5 years

Did you notice any abnormal smell sensations during that time? 0 Yes 0 No If Yes: Explain: ________________________ _

64. Did your smell problem begin with (check all that apply): 0 Accident (specify) _ __________ _ 0 Allergy or sensitivity (specify) _____ _ ______ _ 0 Chemotherapy 0 Exposure (chemicals, smoke, etc.) (specify) ______ ____ _ 0 Illness (specify) ___________ _ 0 Medication (specify) ____________ _ 0 Nasal disease (sinusitis, polyps, etc.) (specify) _ ________ _ 0 Pregnancy 0 Radiation therapy 0 Stroke (specify) ___________ _ 0 Surgery (specify) __________ _ 0 Upper respiratory infection (specify) ____ ________ _ 0 Other (specify) _ __________ _ O Unknown 0 Present since birth

65. Has your ability to detect odors changed? 0 Yes 0 No If No: Go to Question 74. If Yes: Go to question 66.

66. Have you lost all your ability to detect odors? 0 Yes 0 No 67. Have you lost part but not all of your ability to detect odors?

0 Yes ONo If Yes: Explain: ______ _ _______ _____ ____ _

68. How long have you experienced a smell problem? _mo._yrs.

15


69. Can you determine about when your smell problem began? D Yes D No If Yes: When? I I

(Mo.) (Day) (Year)

70. Do you feel that your smell problem is on one or both sides of your nose? D One D Both

If One: Which side? D Right D Left

71. Before your loss of smell, did you experience any strange smell sensations? D Yes D No

IfYes: Explain: ______________________ _

72. Are the majority of odors you detect: D Pleasant D Neutral D Unpleasant

73. Indicate with a check whether your perception of each of the following odors is currently normal, diminished, absent, distorted or heightened (enter "?" if unsure):

Odor Ammonia/Vinegar Body odors Cigarette smoke Flowers Food flavors Household gas Perfumes Smoke Spoiled food Vicks/Menthol

Normal Diminished Absent

74. Do you experience any strange or distorted odors? D Yes D No If No: Go to question 84. If Yes: Got to question 75

75. Does your strange or distorted odor require you to sniff something? D Yes D No

76. How long have had you this smell problem? _mo. _ yrs.

Distorted

77. Can you determine about when your smell problem began? D Yes D No IfYes: When? I I

(Mo.) (Day) (Year)

16

Heightened


78. Can you tell in which nostril(s) you experience smell distortions? 0 Yes 0 No 0 the right nostril only 0 the left nostril only 0 both nostrils

79. Are there any odors that continue to smell normal to you? 0 Yes 0 No If Yes: Specify: _____________________ _

80. Do all of the odors you experience as being distorted smell the same to you? 0 No, different odors still smell differently, they just do not

have the same quality they used to. 0 Yes, they all smell the same.

81. Are the majority of strange or distorted odors you detect: 0 Pleasant 0 Neutral 0 Unpleasant

82. Has there been a change in the quality of the strange or distorted odor since you first noticed it?

0 Yes O No

If Yes: Explain: _______________________ _

83. The kinds of odors that smell distorted (peculiar) to you are (Check all that apply): 0 Foods/beverages (specify): _______________ _ 0 Perfumes (specify): __________________ _ 0 Tobacco products (specify): _______________ _ 0 Other (specify): __________________ _

84. Do you detect a persistent odor that others can't smell (phantosmia)? 0 Yes 0 No If No: Go to question 98. If yes: please continue with question 85.

85. Do you experience more than one type of phantom smell sensation? 0 Yes 0 No If Yes: Explain: ____________________ _

86. How long have you had this smell problem? _months_ years.

87. Can you determine about when your phantom smell began? IfYes: When? I I

(Mo.) (Day) (Year)

88. Do you experience the phantom smell(s): 0 In the right nostril only. 0 In the left nostril only. 0 In both nostrils.

17

0 Yes O No


89. Can other people smell the phantom odor(s) you smell? 0 No, I don't think so.

90. Does the phantom odor occur:

0 Yes, I think so, but no one has commented on it. 0 Yes, I have been told so by others.

0 While breathing in 0 While breathing out 0 While breathing in and out 0 At all times 0 Unsure

91. How frequent is the recurring phantom odor? 0 Always present 0 Occurs several times per day (how many?) __ 0 Weekly 0 Monthly 0 Varies (specify) _________________ _

92. How long does the phantom odor usually last? 0 Fleeting 0 Minutes 0 Hours 0 All day

93. Does the phantom odor begin with a certain event? 0 Yes 0 No If Yes: Explain: ______________________ _

94. What does the odor(s) smell like? (check all that apply) 0 Infected tissue or mucus 0 Smoky or burnt 0 Fecal 0 Rotten 0 Musty 0 Moldy 0 Metallic 0 Salty, sour, sweet, or bitter 0 Pleasant, flower-like (specify) ____________ _ 0 Pleasant, candy-like (specify) ___________ _

18


0 Pleasant, food-like (specify). ___________ _ 0 Other (specify) _______________ _ 0 Unknown

95. Has the phantom odor changed in quality since you first noticed it?

0 Yes O No If Yes: Explain: _____________________ _

96. Does anything cause a variation in the phantom odor? 0 Yes 0 No If Yes: Does the phantom odor increase with: (check all that apply)

0 Crying 0 Putting head down 0 Tickling the inside of the nose 0 Nasal congestion 0 Sleep or rest 0 Exposure to strong odors 0 Other (specify) ___________ _ 0 Unknown 0 Never increases

Does the phantom odor decrease with: (check all that apply) 0 Crying 0 Putting head down 0 Tickling the inside of the nose 0 Nasal congestion 0 Sleep or rest 0 Exposure to strong odors 0 Other (specify) ___________ _ O Unknown 0 Never decreases

97. On average, what is the strength of the phantom odor? O Weak 0 Moderate 0 Strong

SECTION IV - TASTE AND ORAL INFORMATION

98. Check all each of the following statements that apply to you now: 0 My sense oftaste is distorted, that is, things taste peculiar. 0 I experience a taste when nothing is there (phantom taste).

19


0 My sense of taste is heightened (hypersensitive). 0 My sense oftaste is diminished (partial loss). 0 My sense oftaste is absent (complete loss).

0 My sense of taste is normaL•,=====:::::::::. ••••

99. Have you noticed food tasting different as a result ofyour problem? 0 Yes 0 No If Yes: What month and year did it begin tasting different? __ / __

(Mo.) (Year)

How does it taste different? ____________ _

100. Has your appetite changed as a result of your taste problem? 0 Yes 0 No If Yes: Explain: ________________________ _

101. Are there certain foods you avoid since your taste problem began? 0 Yes 0 No IfYes: Speci~: ____________________________ _

102. Are there certain foods you have begun craving since your taste problem began? 0 Yes 0 No lfYes: List: --------------------------------

103. Are there any fluctuations in your taste problem? 0 Yes 0 No If Yes: Does it increase: 0 Before meals (speci~ which meals)

0 After meals (speci~ which meals) -----

Does it decrease:

104. Has the amount of your saliva changed?

0 Before going to sleep 0 After waking up 0 Certain time of the day (speci~ time) ____ _ 0 Other (speci~ exactly what and when) -----

0 Before meals (speci~ which meals) 0 After meals ( speci~ which meals) -----0 Before going to sleep 0 After waking up 0 Certain time ofthe day (speci~ time) -----0 Other (speci~ exactly what and when) -----

If Yes: What month and year did this begin? 0 Yes O No

I

How has it changed?

105. Is your taste problem increased by:

O More 0 Less

(Mo.) (Year)

0 Different (speci~) _________ _

0 Rinsing with ---------0 Chewing 0 Eating 0 Heat or cold

20


0 Certain foods (specify) ____ _ 0 Other (specify) ______ _ 0 Never increases

106. Is your taste problem reduced by: 0 Rinsing with ________ _ 0 Chewing 0 Eating 0 Heat or cold 0 Certain foods (specify) ___ _ 0 Other (specify) ______ _ 0 Never decreases

107. Do you have any pain or soreness in your mouth? 0 Yes 0 No If Yes: Where does the pain or soreness come from: (check all that apply)

0 Whole mouth 0 Throat 0 Gums 0 Dentures or caps 0 Roof of mouth 0 Tongue (specify area) 0 Other (specify) 0 Not sure

How intense is the pain or soreness? O Weak 0 Moderate 0 Strong 0 Excruciating

108. Do you believe your taste problem began with (check all that apply): 0 Accident (specify) _______ _ 0 Allergy or sensitivity (specify) _______ _ 0 Anesthesia (specify) _______ _ 0 Chemotherapy 0 Chronic condition (e.g. allergy, nasal problems, etc.) (specify) ___ ____ _ 0 Dental problems, restorations, or appliances (specify) ________ _ 0 Exposure (chemicals, smoke, etc.) (specify) ________ _ 0 Illness (specify) _______ _ 0 Medication (specify) _____ _ _ _ 0 Oral herpes 0 Oral infections (Candidosis, herpes, fever blisters) (specify) _______ _ 0 Otitis media 0 Pregnancy 0 Radiation therapy 0 Surgery (specify) _______ _

21


0 Other (specify) _______ _ 0 Present since birth O Unknown

109. Has your ability to detect sweet, sour, salty, and/or bitter sensations changed in relation to what it used to be? 0 Yes 0 No

If No: Go to question 112. lfyes: Go to question 110:

110. Has your ability to detect sweet, sour, salty, and/or bitter sensations: 0 Increased 0 Decreased 0 Varies 0 Can't detect at all 0 Unsure

111. Compare your ability to detect sweet, sour, salty, and/or bitter sensations in relation to what they used to be:

Taste Sweet Salty Sour Bitter Metallic Other (specify) ___ _

Better 0 0 0 0 0 0

Same Worse 0 0

0 0 0 0 0 0 0 0 0 0

112. Do you have any taste distortion(s)? (e.g., recurring sweet, salty, sour, or bitter sensations for no reason)? 0 Yes 0 No

If No: Go to question 120. IfYes: Go to question 113

113. Are the taste distortion(s) present at all times or just during eating and drinking? 0 At all times 0 Only while eating or drinking 0 Other; Explain: ___________________ _

114. About how frequently do your taste distortion(s) occur? 0 Less than once a week 0 Once a week 0 Several times a week 0 Once a day 0 Several times a day

22


0 At all times 0 Other; Explain: __________________ _

115. Describe and rate your ability to taste in relation to what it used to be:

Taste Stronger Same Weaker Sweet 0 0 0

Salty 0 0 0

Sour 0 0 0

Bitter 0 0 0

Metallic 0 0 0

Other (specify) 0 0 0

116. Aside from your taste distortion, does anything taste normal to you? 0 Yes 0 No lfYes: Specify: __________________________________________ __

117. Does everything you perceive to be distorted now taste the same to you? 0 No, different things taste differently; they just do not have the same

quality they used to have. 0 Yes, they all taste the same.

118. What specific things taste distorted to you? (Check all that apply) 0 Everything tastes distorted 0 Foods/beverages (specify): __________________ __ 0 Tobacco products (specify): _________________________ _ 0 Other (specify): ________________ _

119. Do you believe your taste distortion arises from your: (Check all that apply) 0 Throat O Gums 0 Dentures or caps 0 Roof of mouth 0 Saliva 0 Post-nasal drip 0 Reflux (secretion of the stomach) 0 Whole mouth 0 Tongue (specify area) ___________ _ D Other (specify) _______________________ _ 0 Not sure

120. Do you experience a phantom taste or burning sensation in your mouth when nothing is there? 0 Yes ONo

121. Have you experienced more than one type of oral phantom sensation? 0 Yes 0 No If Yes: Explain: ___________________ _

23


122. Can you determine about when your taste phantom began? 0 Yes O No IfYes: When? I I

(Mo.) (Day) (Year)

123. Do you currently experience more than one type of oral phantom sensation? 0 Yes O No If Yes: Explain: ___________________ _

124. Where do you believe your oral phantom comes from? (Check all that apply) 0 Throat O Gums 0 Dentures or caps 0 Roof of mouth 0 Saliva 0 Post-nasal drip 0 Reflux (secretion of the stomach) 0 Whole mouth 0 Tongue (specify area) ___________ _ 0 Other (specify) ___________ _ 0 Not sure

125. Has the oral phantom changed in quality since you first noticed it? 0 Yes O No

If Yes: Explain: _ __________________ _

126. How frequently do you experience your oral phantom? 0 Always present 0 Occurs several times per day (how many?) __ 0 Weekly 0 Monthly 0 Varies (specify) _____ ______________ _

127. What is the typical duration ofthe oral phantom? 0 Fleeting 0 Minutes 0 Hours 0 All day

128. Does the phantom taste begin with a certain event? 0 Yes D No If Yes: Explain: _____________________ _

129. On average, what is the strength of the oral phantom? O Weak 0 Moderate 0 Strong

24

Hotel Accommodations

The Hospital of the University of Pennsylvania is close to several hotels. Below is a partial list. When making reservations as a patient or family member, be sure to ask for the hospital room rate. Note: Please be aware that this list is not a complete listing of Philadelphia area hotels and that inclusion on this list does not necessarily imply endorsement by the University of Pennsylvania Health System.

~- Hotel I Hospital Room Rate

,1 __________ ~----Hotel -~ Hospital

Room Rate

Comfort Inn 100 N. Christopher Columbus Drive (215) 627-7900 or (800) 228-5150 Fax: (215) 627-0809

4 miles from HUP. Located at Penn's Landing .

Marriott Residence Inn Studio Suites 4630 Island Ave. (215) 492-1611 Fax:(215) 492-1665

I Clarion Suites 9000 Bartram Ave. 10th and Arch Sts. Approx. 2.5 miles from HUP in (215) 922-1730 Center City 1_(800) EMBASSY Fax: (215) 922-6258 Fax: (215) 365-3195

,-------

Near Phila . International Airport; 5 miles from HUP

Near Phila. International Airport; 5 miles from HUP

I - ---f ~mbassy Suites Hotel

I 215) 365-4500 or

,------------- --------~------

I Divine Tracy Hotel 20 S. 36th St. (215) 382-4310 Fax: (215) 387-0157

4.5 Blocks from HUP.

Sheraton University City 36th and Chestnut Streets (215) 387-8000 or (877) 459-1146

I Fax: (215) 387-5339

In University City, 5 blocks from HUP

-----------r------------------·,--------------------.---------

I Double Tree Hotel Broad and Locust Streets (215) 893-1600 Fax: (215) 893-1664

In Center City, 2 miles from HUP

Radison Plaza Warwick Hotel 1701 Locust St. (215) 790-7781 or (800) 523-4210


Fax:(215) 790-6105 ,-----------'.-------------r--------------,-------1 Four Seasons Hotel

One Logan Square (215) 963-1500 Fax: (215) 963-9507

Holiday Inn Express Midtown 1305 Walnut Street Phila., Pa. 19102 (215) 735-9300 or (800) 564-3869 Fax: (215)732-2598

~he Inn at Penn 3600 Sansom St. (215) 222-0200

I Fax: (215) 222-4600

Latham Hotel

I

17th and Walnut Sts. (215) 563-7474 Fax: (215) 568-0110

-

Approx. 2 miles from HUP in Center City.

Best Western 501 N.22nd Street Philadelphia , Pa. 19130 (215) 568-8300 Fax: (215) 557-9448

4.5 miles from HUP

-,-------------,-------------.------


The Windsor 700 Ben Franklin Parkway (215) 981-5678 Fax:(215) 981-5684

Valet parking $22.00/day with in and out privileges

,-- -~--.------

On Penn campus, 4 blocks from HUP

In Center City Phila ., 2 miles from HUP.

1 Hawthorn Suites 11 00 Vine Street

I

(215) 829-8300 or (800) 527-1133 Fax: (215) 282-1806

The Ritz Carlton 10 Avenue of the Arts (215) 735-7700 Fax:(215) 735-7710

PARKING

VALET PARKING

Self-Parking $17/day; Valet parking $21 .00/day

r:-miles from

I HUP

Valet parking is available outside the Hospital of the University of Pennsylvania at the following locations:

Ravdin Entrance 34th Street, south of Spruce Street

Monday-Friday, 6:00a.m. to 10 p.m. Saturday, 12 p.m. to 5 p.m.

Penn Tower Motor Lobby Lower Motor Lobby

Convention Boulevard Monday-Friday, 7 a.m. to 6 p.m.

Self Parking is available in the Penn Tower Parking Garage

Please park in the Penn Towers parking garage. All patients must pay for parking, however when you go to pay on your way out, inform the attendant that you are a patient and you will receive a discounted rate for parking.

Direction from the Walt Whitman Bridge

Take the ramp onto 1-76 W Partial toll road Entering Pennsylvania Take exit 346A on the left for South Street Turn left onto South St South St turns slightly left and becomes Spruce St Turn left onto S 34th St Hospital ofthe University of Pennsylvania is on right

From I 95

Take 1-95 take ramp to 1-676/Central Phila/1-76 Follow signs for 1-76 Ellnternational Airport and merge onto 1-76 E Take exit 346A on the left for South Street Turn left onto South St South St turns slightly left and becomes Spruce St Turn left onto S 34th St Hospital of the University ofPennsylvania is on right

Documents

Penn Medicine Penn Medicine Hospital of the University of Pennsylvania Smell and Taste Center Department of Otorhinolaryngology Please read carefully through the instructions below