Please Complete Questionnaire
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Question 1 of 73
Name
Question 2 of 73
Date
Question 3 of 73
D.O.B.
Question 4 of 73
Address
Question 5 of 73
Email
Check the appropriate column for liking, neutral feeling towards, dislike, made sick by, for each substance.
Question 7 of 73
Smoke from coal fires
Like
Neutral
Dislike
Sick
Question 8 of 73
Odor of escaping natural gas
Question 9 of 73
Odor of burning natural gas
Question 10 of 73
Odor of petrol
Question 11 of 73
Garage fumes and odors
Question 12 of 73
Car Exhaust
Question 13 of 73
Odor of naphtha, cleaning or lighter fluid
Question 14 of 73
Odor of recently cleaned clothing or material
Question 15 of 73
Odor of nail polish or polish remover
Question 16 of 73
Odor of brass, metal, or shoe polish
Question 17 of 73
Odor of fresh newspapers
Question 18 of 73
Odor of paraffin, paraffin burners
Question 19 of 73
Odor of diesel engine fumes, trains, buses
Question 20 of 73
Odor of lubricating grease, crude oil
Question 21 of 73
Odor of car fumes from excess oil burnt
Question 22 of 73
Odor of burning greasy rag fumes
Question 23 of 73
Mineral oil used for laxatives
Question 24 of 73
Cold cream, foundation cream
Question 25 of 73
Vaseline, petroleum jelly, ointments
Question 26 of 73
Floor or furniture wax
Question 27 of 73
Fumes from burning wax candles
Question 28 of 73
Fumes from tarring roofs or roads
Question 29 of 73
Tar-containing soaps, shampoos
Question 30 of 73
Ink, carbon paper, typewriter ribbon
Question 31 of 73
Clothing and shoe dyes
Question 32 of 73
Cosmetic dyes, lipsticks, etc
Question 33 of 73
Odor of disinfectants
Question 34 of 73
Household detergents
Question 35 of 73
Deodorants
Question 36 of 73
Odor of phenol (carbolic acid) or Lysol
Question 37 of 73
Materials with phenol preservatives
Question 38 of 73
Odor of rubber - gloves, elastic
Question 39 of 73
Sponge-rubber bedding, typewriter pads
Question 40 of 73
Rubber tires, car accessories
Question 41 of 73
Rubber-backed rugs or carpets
Question 42 of 73
Odor of contact with plastics
Question 43 of 73
Spectacle, frames, or dentures
Question 44 of 73
Plastics in department stores
Question 45 of 73
Nylon tights or clothes
Question 46 of 73
Rayon or cellulose-acetate material
Question 47 of 73
Adhesive tape
Question 48 of 73
Plastic cement
Question 49 of 73
Medication with alcohols or glycols odor of: varnish, lacquer, shellac, drying paint
Question 50 of 73
Odor of after shave, hair tonics/oils
Question 51 of 73
Odor of scented shampoos or soaps
Question 52 of 73
Odor of perfumes or colognes
Question 53 of 73
Odor of hairspray
Question 54 of 73
Odor of burning incense fumes
Question 55 of 73
Odor of moth balls
Question 56 of 73
Odor of insecticide sprays
Question 57 of 73
Odor of weed killers
Question 58 of 73
Odor of formalin or formaldehyde
Question 59 of 73
Odor of chlorinated water
Question 60 of 73
Drinking of chlorinated water
Question 61 of 73
Sulfur dioxide fumes
Question 62 of 73
Ammonia fumes
Question 63 of 73
Odor of pine trees
Question 64 of 73
Odor of sanding or working with pine or cedar
Question 65 of 73
Odor of cedar scented furniture polish
Question 66 of 73
Odor of pine scented household deodorants
Question 67 of 73
Odor of pine scented bath oils, shampoos, soaps
Question 68 of 73
Turpentine or turpentine containing paint
Question 69 of 73
Are there any other odors that you particularly like?
Question 70 of 73
Any others that you dislike?
Question 71 of 73
Do you smoke?
If so, How many a day?
cigarettes
pipe
cigar
other
Question 72 of 73
If you smoke/did smoke:
What age did you start smoking?
What age did you last stop smoking?
Question 73 of 73
General Comments: