Toulouse Olfactory Assessment Questionnaire
Please complete this questionnaire to help assess your sense of smell and related factors.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Other
Email Address
*
example@example.com
Do you have any of the following medical conditions? (Select all that apply)
Chronic sinusitis
Allergic rhinitis
Neurological disorders
None of the above
Other
Do you smoke?
*
Yes
No
Former smoker
Have you been exposed to chemicals or strong odors at work or home?
*
Yes
No
Please rate your sense of smell over the past month.
*
1
2
3
4
5
Olfactory Symptoms Assessment
*
Rows
Never
Rarely
Sometimes
Often
Always
I notice a reduced ability to smell things.
1
2
3
4
5
I have difficulty identifying familiar odors.
6
7
8
9
10
I experience unpleasant or distorted smells.
11
12
13
14
15
My sense of smell affects my appetite.
16
17
18
19
20
My sense of smell affects my daily activities.
21
22
23
24
25
Have you noticed any recent changes in your sense of smell?
*
No change
Slight decrease
Significant decrease
Complete loss
Fluctuating
Please describe any other symptoms or comments related to your sense of smell.
Signature
*
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