Sense of Smell and Taste

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

C. Physical Examination (Objective Findings):

D. Diagnostic and Clinical Tests:

1. For sense of smell, test each side of nose separately. State results with the following substances recommended for testing:

1. Coffee.
2. Soap.
3. Oil of lemon.
4. Other (state substance).

2. For sense of taste

a. Using electrogustometry if available, test for:

1. Sweet.
2. Sour.
3. Bitter.
4. Salt.

b. State results with the following substances recommended for testing:

1. Sugar.
2. Diluted acetic acid.
3. Lemon or Orange.
4. Salt.

3. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Provide:

1. State whether loss of sense of smell is partial or complete, and its basis.
2. State whether loss of sense of taste is partial or complete, and its basis.
3. If a psychiatric basis is suspected, a special psychiatric examination should be ordered.