To request an appointment at NYOG by email, please give us your contact information in the form below and we will get back to you shortly with available dates.
You can also call the office:
212.889.8575
We take most insurance plans. Please call the office
to see if we accept yours.
Anosmia Treatment NYC Questionnaire | Ear Nose Throat Specialists
212.889.8575
2 Manhattan, NYC Offices
Most Major Insurance Accepted
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New York Sinus Center
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Hearing Disorders
Hearing Loss
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Otosclerosis Symptoms, Causes, and Treatment
Cholesteatoma – Symptoms, Diagnosis, and Treatment
Ossicular Chain Discontinuity
Ear Drum Surgery for Perforations
Autoimmune Inner Ear Disease
Vertigo & Balance Disorders
Meniere’s Disease
Tinnitus Causes and Treatment
Hearing Loss Causes
Hearing Loss Treatment
Hearing Preservation for Musicians
Hearing Aids
Halo Hearing Aid
Implantable Hearing Devices
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New York Voice Center
Voice
Diagnosis
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Speech
Speech Diagnosis
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Swallowing
Diagnosis
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The Professional Voice
Diagnosis
Treatment
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Facial Plastics Center
About
ULTHERAPY
Information for Patients – Cosmetic Surgery
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Browlift
Eyelid Surgery
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Fat Transfer
Cosmetic Rhinoplasty
Nasal Trauma
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Facelift
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New York Sinus Center
- Sinusitis
- Sinusitis Signs & Symptoms
- Underlying Causes of Sinusitis
- Sinusitis Diagnosis & Treatment
- Sinus Surgery
- Radiology and Sinus Disorders
- What to Expect from Sinus Surgery
- Anosmia / Loss of Smell
- Sinusitis FAQ
- Doctors
- Questionnaires and Forms
- Links
Head and Neck Surgery Center
- Head & Neck Cancer
- Cancer & Tobacco
- Other Risk Factors
- Head and Neck Cancer Symptoms
- Mouth Cancer Diagnosis and Treatment
- Surgery
- Head and Neck Surgery Rehabilitation
- Parathyroid Disease
- Parathyroid Disease Symptoms
- Parathyroid Disease Diagnosis and Treatment
- Parathyroid Disease Surgery
- Thyroid Disorders
- Benign Thyroid Tumors
- Thyroid Cancer
- Diagnosis & Treatment
- Head & Neck Cancer Surgery FAQ
- Questionnaires and Forms
- Links
Hearing & Balance Center
- Hearing Disorders
- Hearing Loss
- Ear Pain
- Ear Infections (Otitis Media) in Children
- Otosclerosis Symptoms, Causes, and Treatment
- Cholesteatoma – Symptoms, Diagnosis, and Treatment
- Ossicular Chain Discontinuity
- Ear Drum Surgery for Perforations
- Autoimmune Inner Ear Disease
- Vertigo & Balance Disorders
- Meniere’s Disease
- Tinnitus Causes and Treatment
- Hearing Loss Causes
- Hearing Loss Treatment
- Hearing Preservation for Musicians
- Hearing Aids
- Halo Hearing Aid
- Implantable Hearing Devices
- Bone Anchored Hearing Aids (BAHAs)
- Cochlear Implants (CI)
- Earlens Light-Driven Hearing Aid
- Ear Surgery
- Stapedotomy Surgery
- Ossicular Chain Reconstruction
- Ear Tube Surgery
- How the Ear Works
- Online Hearing Test
- Testimonials
- Questionnaires and Forms
- Glossary
- Links
New York Voice Center
- Voice
- Diagnosis
- Treatment
- Pitch Lowering Surgery to Alter Voice
- Speech
- Speech Diagnosis
- Speech Therapy and Training
- Swallowing
- Diagnosis
- Treatment
- The Professional Voice
- Diagnosis
- Treatment
- FAQ's
- Doctors
- Questionnaires and Forms
- Links
Facial Plastics Center
- About
- ULTHERAPY
- Information for Patients – Cosmetic Surgery
- Rhinoplasty (Plastic Surgery) – Preparing and What to Expect
- Browlift
- Eyelid Surgery
- Facelift Surgery
- Facial Implants Preparation, Day of Surgery, and Post-Operative Care
- Photo Galleries
- Fat Transfer
- Cosmetic Rhinoplasty
- Nasal Trauma
- Blepharoplasty
- Facelift
- Nasal Valve Reconstruction
The New York Otolaryngology Group
Questionnaires and Forms
Anosmia / Loss of Smell Questionnaire
Anosmia / Loss of Smell Questionnaire
Take this questionnaire to see if Anosmia Treatment NYC is right for you.
Anosmia / Loss of Smell Questionnaire
We would love to hear from you! Please fill out this form and we will get in touch with you shortly.
Name
First
Last
Phone
Email
Date of Onset
Loss of Smell - Check all that apply
Complete
Partial
Sudden
Gradual
Distorted Sense of Smell
Loss of Taste - Check all that apply
Cannot taste sweet
Cannot taste bitter
Cannot taste sour
Distorted sense of taste
Other Symptoms - Check all that apply
runny nose
post nasal drip
difficulty breathing through nose
mouth breathing
burning tongue
burning mouth
dry mouth
dry eyes
frequent yeast infections
migraine headaches
My symptoms began: (check all that apply)
after a cold or flu
after a head injury
after change in medication
after environmental exposure
other
Your Medical History - Check all that apply
environmental allergies
9/11 environmental exposure
nasal polyps
previous nose or sinus surgery
previous ear surgery
previous brain surgery
liver disease
glandular problems
thyroid problems
diabetes
Sjogren's Syndrome
dental problems
dentures
recent mouth, throat or oral surgery
psychiatric problems
depression
previous chemotherapy
tobacco use
vitamin or mineral deficiency
For Women Only:
post menopause
hysterectomy / ovarian removal
Please describe any tumors or cancers you have had or currently have:
Please describe any neurologic problems you have had or currently have:
Mouthwash you use (and how long you've been using it)
Toothpaste you use (and how long you've been using it)
Please use this box to provide any other information about your condition:
I would like a scheduler from your office to contact me:
By Phone
By Email
I do not want to be contacted. I will contact you.
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