Oral Health Assessment Please enable JavaScript in your browser to complete this form.Date / TimeDateTimeDate & Time of this Incident ReportRate Ability to TasteRate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10On a scale of 1-10, 10 being worst, how would you rate your current ability to taste things like you did prior to COVID?Characterize Current Taste Sour TasteFoul TasteSweet TastePeppery TasteMetallic TasteBurningNumbnessLoss of TastePlease select all that applyHow is this Affecting Your Ability to Eat?UnaffectedLoss of AppetiteCan't Eat Certain FoodsLost Interest in EatingIs there anything that you can do to reduce the fatigue from COVID-19?How is this Affecting Your Ability to SwallowUnaffectedDifficulty Swallowing SolidsDifficulty Swallowing LiquidsGag Reflex TriggeredRegurgitate foods-fluidsEsophageal PainHeartburnIs there anything that you can do to reduce the fatigue from COVID-19?Check Things That Taste Normal or PleasantSaltSweets-SugarBitter SubstancePepper-SpiceFruitsVegetablesSeafoodsMeatsAlcoholWaterPlease select all that applyWhat Helps Improve Your Ability to Taste?NothingFlushing Mouth w WaterBrushing teethFlossingMouthwashSalt-water SolutionEatingFastingAlcoholMedicationOtherPlease select all that applyTongue EvaluationNormalWhite CoatingRedSwollenPainfulSome paralysisSores-bleedingSwollen tastebudsPlease select all that applyArea of the Tongue That is AffectedWhole TongueMiddle-SurfaceLeft SideRight SideTipBack of TongueThroatPlease select all that applyDisability IndexRate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10On a scale of 1-10, 10 being worst, how would you rate the impact that COVID Long-haul taste problems is having on your ability to function.Add Diary Note Concerning Taste for This Episode COVID-19 Sense of SmellChanges in Ability to Smell (Olfaction)A common complaint of COVID-19 Long-haul survivors is that they have lost their ability to smell things normally. Report changes in your ability to smell things here.Rate Ability to SmellRate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10On a scale of 1-10, 10 being worst, how would you rate your current ability to smell things like you did prior to COVID?Prior to COVID Check All that ApplyNormal Smell Prior to COVIDDiminished due InfectionDiminished due SmokingDiminished due Dental ProblemDiminished due MedicationDiminished Prior Head InjuryOtherPlease select all that applyTest Your Ability & Report If You Can Smell Any of the Following:Fragrances-FlowersWoody-Resinous SmellsNon-citrus Fruity SmellsSharp-Pungent SmellsChemical Smells Mint-PeppermintSweetPopcornSickeningLemonPlease select all that applyNasal EvaluationNormalStuffed NoseRunny NoseSore NosePrior InjuryBroken NoseFrequent Nose BleedsAllergiesPlease select all that applySmell Disability IndexRate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10On a scale of 1-10, 10 being worst, how would you rate the impact that COVID Long-haul smell abnormalities are having on your ability to function.Add Diary Note Concerning Smell for This EpisodeSpeech & Voice ChangesCOVID-19 Impact on Ability to Speak NormallyRate Ability to SpeakRate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10On a scale of 1-10, 10 being worst, are you having trouble speaking or enunciating words?This Episode is:Increasing SignificantlyIncreasing SomewhatHolding SteadyDecreasing SomewhatResolvedHow would you describe this incident against others you have experienced.How Did This Incident OnsetSuddenlyGradually IncreasedFluctuatesAfter SleepAfter EatingHow would you describe this incident against others you have experienced.Do You Do Anything to Improve Ability to Speak?NoRestSleepMedicationMouthwashGargleHeatFluidsSpeak-Sing OtherIs there anything that you can do to reduce the fatigue from COVID-19?Speech Disability Index Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10On a scale of 1-10, 10 being worst, how would you rate the impact that COVID Long-haul speech abnormalities are having on your ability to function.Submit