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Protocol - Personal and Family History of Hearing Loss

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Description:

The Age-Related Hearing Impairment (ARHI) instrument is a self-administered questionnaire that asks about an individual’s hearing impairment history, history of ear diseases and operations, family history, and history of exposure to loud noises.

Specific Instructions:

Add hearing loss history from other family members.

Protocol:

Hearing impairment

Please only give one answer to each question. When the question calls for you to enter a year field, then please enter as yyyy.

1. Do you have any difficulty with your hearing?

[ ] No

[ ] Yes

If “YES,”

1.1. In which ear(s) do you have a hearing difficulty?

[ ] Left

[ ] Right

[ ] Both

1.2. At what age did you first notice a hearing difficulty?

[ ] I have had a hearing difficulty since I was born

[ ] My hearing difficulty developed during my childhood years (before the age of 15)

[ ] My hearing difficulty developed between the ages of 15 and 40

[ ] My hearing difficulty developed after the age of 40

1.3. How quickly did your hearing difficulty develop?

[ ] Suddenly (over a few days)

[ ] Over a few months

[ ] Over several years

1.4. Do you know the reason for your hearing difficulty? (If there is a separate cause for each of your ears, please note them accordingly).

[ ] I have no idea about the cause of my hearing problem

[ ] Yes

___________________________________________________________

___________________________________________________________

1.5. Does your hearing vary from day to day?

[ ] No

[ ] Yes, in both ears

[ ] Yes, in my left ear

[ ] Yes, in my right ear

2. Do you find it very difficult to follow a conversation if there is background noise (e.g., TV, radio, children playing)?

[ ] No

[ ] Yes

3. Are you particularly sensitive to loud sounds?

[ ] No

[ ] Yes

4. Do you sometimes feel a fullness or blockage in your ears?

[ ] No

[ ] Yes, in my left ear

[ ] Yes, in my right ear

[ ] Yes, in both ears

5. Nowadays, do you ever get noises in your head or ears (tinnitus) which usually last longer than five minutes?

[ ] No

[ ] Yes

Ear diseases and balance

6. Have you ever had an ear disease that has caused your hearing to get worse?

[ ] No

[ ] Yes

7. Have you ever had discharge of blood or pus, or smelly discharge (not wax) from either ear?

[ ] No

[ ] I don’t know

[ ] From my left ear

[ ] From my right ear

[ ] From both ears

8. Have you ever had an ear operation?

[ ] No

[ ] I don’t know

[ ] Yes

If “YES,” please also answer the following questions (a–c). Please fill in one row for each operation.

a. Write down what type of operation, or why the operation was performed

 b. Which ear?

  c. Which year? (approximately)

8.1.

[ ] left ear

[ ] right ear

8.2.

[ ] left ear

[ ] right ear

8.3.

[ ] left ear

[ ] right ear

8.4.

[ ] left ear

[ ] right ear

9. Have you ever suffered from attacks of dizziness in which things seem to spin around you?

[ ] No

[ ] Yes, within the last year

[ ] Yes, more than a year ago

10. Do you feel unsteady when walking in the dark?

[ ] No

[ ] Yes

Hereditary Factors

From a genetical point of view, it is important that we establish where your ancestors originated from.

11. Concerning your grandparents:

11.1. Where did your mother's father (your maternal grandfather) originate from?

Country:____________________ Region: ____________________

11.2. Where did your mother's mother (your maternal grandmother) originate from?

Country:____________________ Region: ____________________

11.3. Where did your father's father (your paternal grandfather) originate from?

Country:____________________ Region: ____________________

11.4. Where did your father's mother (your paternal grandmother) originate from?

Country:____________________ Region: ____________________

12. As far as you know, does/did your mother have hearing problems?

[ ] No

[ ] Yes

If “YES,”

12.1. What was her year of birth? _____________________

12.2. What was her occupation? ______________________________________

12.3. At what age did her hearing problems start? ___________________________

12.4. What is/was the cause of her hearing problem (if known)? _________________

13. If she is dead, how old was she when she died? ___________________________

14. As far as you know does/did your father have hearing problems?

[ ] No

[ ] Yes

If “YES,”

14.1. What was his year of birth? _____________________

14.2. What was his occupation? _________________________________________

14.3. At what age did his hearing problems start? ____________________

14.4. What is/was the cause of his hearing problems (if known)? _______________

15. If he is dead, how old was he when he died? ______________

16. Do you have any brothers or sisters with normal hearing?

[ ] No

[ ] Yes: (how many of your brothers/sisters have normal hearing?) _________

17. Do you have any brothers or sisters with hearing difficulties?

[ ] No

[ ] Yes: (how many of your brothers/sisters have hearing difficulties?) _________

If “YES,” please answer the following questions (a–d). Please fill in one row for each brother/sister with hearing difficulties.**

a. Sex

b. Year of birth

c. Age at onset of hearing difficulties

d. Cause of hearing difficulties (if known)

17.1.

[ ] M
[ ] F

17.2.

[ ] M
[ ] F

17.3.

[ ] M
[ ] F

17.4.

[ ] M
[ ] F

** If needed, you can add extra copies of this page.

18. Do you have any children with normal hearing?

[ ] No

[ ] Yes: (how many of your children have normal hearing?) ____________

19. Do you have any children with hearing difficulties?

[ ] No

[ ] Yes: (how many of your children have hearing difficulties?) _________

If “YES,” please also answer the following questions (a–d). Please fill in one row for each child with hearing difficulties.**

a. Sex

b. Year of birth

c. Age at onset of hearing difficulties

d. Cause of hearing difficulties (if known)

19.1.

[ ] M
[ ] F

19.2.

[ ] M
[ ] F

19.3.

[ ] M
[ ] F

19.4.

[ ] M
[ ] F

** If needed, you can add extra copies of this page.

20. Do you have uncles, aunts, cousins, nephews, or nieces with hearing difficulties?

[ ] No

[ ] Yes

21. Do you know if any of your relatives have already participated in this investigation?

[ ] As far as I know, none of my relatives has already participated in this investigation.

[ ] One of my relatives has already participated in this investigation (please write down the name of your relative and the relation between you) _____________________

General Health

22. Do you suffer from migraine?

[ ] No

[ ] Yes

If “YES,”

22.1. How often do you generally have attacks?

[ ] Often (more than one attack a month)

[ ] Regularly (an attack once a month on average)

[ ] Sporadically (between 4 and 10 times a year)

[ ] Rarely (less than one attack every 3 months)

23. Have you ever suffered a hearing loss from meningitis or encephalitis?

[ ] No

[ ] I don’t know

[ ] Yes: in _________________ (write down in which year(s) approximately)

24. Have you ever had a whiplash injury?

[ ] No

[ ] I don’t know

[ ] Yes: in _________________ (write down in which year(s) approximately)

25. Have you ever been knocked unconscious (e.g., in a traffic accident, contact sport, a fight or after a fall)?

[ ] No

[ ] I don’t know

[ ] Yes: in _________________ (write down in which year(s) approximately)

26. Have you ever had a heart attack?

[ ] No

[ ] Yes: in _________________ (write down in which year(s) approximately)

27. Have you ever had heart surgery?

[ ] No

[ ] Yes

If “YES,”

27.1. What operation(s)? (Please describe) ___________________________________________

_______________________________________________

27.2. In which year(s) approximately? ________________________

28. Have you ever had coronary artery catheterization?

[ ] No

[ ] Yes

If “YES,”

28.1. What type of intervention(s) (e.g., stent, balloon dilatation)? __________________________

______________________________________________

28.2. In which year(s) approximately? __________________________

29. Have you ever had a stroke?

[ ] No

[ ] I don’t know

[ ] Yes: in _________________ (write down in which year(s) approximately)

30. Have you ever had an operation on your carotid artery?

[ ] No

[ ] I don’t know

[ ] Yes: in _________________ (write down in which year(s) approximately)

31. Do you suffer from intermittent claudication? (This is if you can't walk more than 200 metres, because you get cramps in your legs, and when you stand still for a moment the pain gets better)

[ ] No

[ ] I don’t know

[ ] Yes

32. Do you have other problems with your heart or circulation?

[ ] No

[ ] Yes: ___________________________________________ (please write down which problems)

33. Do you suffer from diabetes?

[ ] No

[ ] I don’t know

[ ] Yes

If “YES,”

33.1. Do you need insulin?

[ ] No

[ ] Yes

34. Please indicate if you suffer from one or more of the following diseases:

If you suffer from one or more of these diseases, please describe your disease on the last row (34.14).

34.1. Osteoporosis

[ ] No

[ ] Yes

34.2. Osteoarthritis

[ ] No

[ ] Yes

34.3. Multiple sclerosis (MS)

[ ] No

[ ] Yes

34.4. Epilepsy

[ ] No

[ ] Yes

34.5. Lung problems

[ ] No

[ ] Yes

34.6. Allergy

[ ] No

[ ] Yes

34.7. Diseases of the stomach or intestines

[ ] No

[ ] Yes

34.8. Kidney diseases

[ ] No

[ ] Yes

34.9. Liver diseases

[ ] No

[ ] Yes

34.10. Skin diseases

[ ] No

[ ] Yes

34.11. Psychiatric problems

[ ] No

[ ] Yes

34.12. Blood diseases

[ ] No

[ ] Yes

34.13. Diseases of the thyroid gland

[ ] No

[ ] Yes

34.14. Please describe your disease(s):

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

35. Please indicate if you suffer from one or more of the following autoimmune diseases:

35.1. Rheumatoid arthritis (rheumatism)

[ ] No

[ ] Yes

35.2. Inflammatory bowel disease (Crohn’s disease/colitis ulcerosa)

[ ] No

[ ] Yes

35.3. Lupus erythematosus

[ ] No

[ ] Yes

35.4. Psoriasis

[ ] No

[ ] Yes

35.5. Wegener's granulomatosis

[ ] No

[ ] Yes

35.6. Vasculitis

[ ] No

[ ] Yes

35.7. Nephritis

[ ] No

[ ] Yes

35.8. Hashimoto thyroiditis

[ ] No

[ ] Yes

35.9. Cogan's syndrome

[ ] No

[ ] Yes

35.10. Behcet’s syndrome

[ ] No

[ ] Yes

35.11. Other autoimmune diseases:

__________________________________________________________________

__________________________________________________________________

36. Have you ever had other operations (not covered by the previous questions)?

[ ] No

[ ] Yes: (Please list any operations you have had and the year they were performed)

36.1.

___________________________ in:___________

36.2.

___________________________ in:___________

36.3.

___________________________ in:___________

36.4.

___________________________ in:___________

36.1.

___________________________ in:___________

37. Do you have other serious health problems that are not covered by the previous questions?

[ ] No

[ ] Yes

If “YES,”

37.1. Please describe these problems:

___________________________________________________________________

Medication

38. Have you ever been treated for a serious infection with an antibiotic (other than penicillin) which was administered by injection/drip for a week or more?

[ ] No

[ ] Yes

38.1. If “YES,” for what sort of infections did you receive these antibiotics?

_______________________________________________________________

38.2. In which year(s) approximately?______________________

39. Have you had cancer or leukemia?

[ ] No

[ ] Yes

If “YES,”

39.1. Which kind of cancer or leukemia?

____________________________________________________________

39.2. Have you been treated with chemotherapy or other medication for this condition?

[ ] No

[ ] Yes

39.3 If “YES,” with_____________________________________________________ (please fill in which medication if you know it)

39.3 in __________________________ (in which year(s) approximately)

40. Have you ever received radiotherapy to your head or neck for a tumour?

[ ] No

[ ] Yes

If “YES,”

40.1. What kind of tumour(s)? ________________________________________

40.2. In which year(s) approximately? __________________________

41. On average how often do you take painkillers?

[ ] never

[ ] less than 1 tablet a month

[ ] less than 1 tablet a week (but more than one each month)

[ ] 2–5 tablets a week

[ ] 2–5 tablets a day

[ ] more than 5 tablets a day

42. Do you take aspirin on a daily basis for your heart or to dilute your blood?

[ ] No

[ ] Yes

42.1. If “YES,” how long have you been taking aspirin so far?

3[ ]months–1 year

[ ] 1–5 years

[ ] more than 5 years

43. Please list all of the medication you have taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis.

Please write down the medical reason why you had or have to take this medication. If necessary, you can add an additional copy of this page.

43.1. Name drug: ________________________

43.2. Medical reason: ________________________

43.3. Duration of treatment

3[ ]months–1 year

[ ] 1–5 years

[ ] more than 5 years

43.4. Name drug: ________________________

43.5. Medical reason: ________________________

43.6. Duration of treatment

3[ ]months–1 year

[ ] 1–5 years

[ ] more than 5 years

43.7. Name drug: ________________________

43.8. Medical reason: ________________________

43.9. Duration of treatment

3[ ]months–1 year

[ ] 1–5 years

[ ] more than 5 years

43.10. Name drug: ________________________

43.11. Medical reason: ________________________

43.12. Duration of treatment

3[ ]months–1 year

[ ] 1–5 years

[ ] more than 5 years

43.13. Name drug: ________________________

43.14. Medical reason: ________________________

43.15. Duration of treatment

3[ ]months–1 year

[ ] 1–5 years

[ ] more than 5 years

43.16. Name drug: ________________________

43.17. Medical reason: ________________________

43.18. Duration of treatment

3[ ]months–1 year

[ ] 1–5 years

[ ] more than 5 years

43.19. Name drug: ________________________

43.20. Medical reason: ________________________

43.21. Duration of treatment

3[ ]months–1 year

[ ] 1–5 years

[ ] more than 5 years

43.22. Name drug: ________________________

43.23. Medical reason: ________________________

43.24. Duration of treatment

3[ ]months–1 year

[ ] 1–5 years

[ ] more than 5 years

43.25. Name drug: ________________________

43.26. Medical reason: ________________________

43.27. Duration of treatment

3[ ]months–1 year

[ ] 1–5 years

[ ] more than 5 years

43.28. Name drug: ________________________

43.29. Medical reason: ________________________

43.30. Duration of treatment

3[ ]months–1 year

[ ] 1–5 years

[ ] more than 5 years

Noise Exposure

44. Have you ever fired a gun?

[ ] No

[ ] Yes

If “YES,” please answer the following questions.

Type of weapon

44.1. Estimate the total number of shots fired

44.2. Did you use ear protection?

44.3. If any, which type of ear protection did you use?

Light weapons

(rifles/shotguns)

[ ] less than 10 shots
[ ] 10–100 shots
[ ] 101–1,000 shots
[ ] 1,001–10,000 shots
[ ] more than 10,000 shots

[ ] always
[ ] most of the time
[ ] more than 50% of the time
[ ] less than 50% of the time
[ ] never

[ ] plugs
[ ] earmuff
[ ] “active” protection
[ ] several

Heavy weapons

(artillery/bazookas)

[ ] less than 10 shots
[ ] 10–100 shots
[ ] 101–1,000 shots
[ ] 1,001–10,000 shots
[ ] more than 10,000 shots

[ ] always
[ ] most of the time
[ ] more than 50% of the time
[ ] less than 50% of the time
[ ] never

[ ] plugs
[ ] earmuff
[ ] “active” protection
[ ] several

45. During your leisure time, are you/have you been regularly (more than once a week) exposed to loud sound or noise (so that you have to shout to make yourself heard by someone who was more than 1 m away from you)?

[ ] No

[ ] Yes

If you answered “YES,” please also answer the following questions (44.1–44.5).

45.1. What kind of loud sound? ___________________________________________

45.2. For how many years have you been exposed to this loud sound? ______________

45.3. How many hours per week have you been exposed to this loud sound?

[ ] 1–3 hours each week

[ ] 3–10 hours each week

[ ] 1–3 hours each day

[ ] More than 3 hours each day

45.4. Did you use ear protection?

[ ] Always

[ ] Most of the time

[ ] More than 50% of the time

[ ] Less than 50% of the time

[ ] Never

45.5. If any, which type of ear protection did you use?

[ ] Plugs

[ ] Earmuff

[ ] “Active” protection

[ ] Several

Occupational Information

46. What is/was your job?

____________________________________________________________

47. Have you been exposed to solvents (e.g., thrichloroethylene, toluene, evaporations from paints or lacquers) for more than one year in one of your jobs?

[ ] No

[ ] Yes

If “YES,”

47.1. Which solvents? ____________________________________________________________

47.2. In which year did the solvent exposure start? _______________

47.3. For how many years were you exposed to solvents? ______________

47.4. For how many hours per day were you exposed to solvents?

[ ] Less than 1 hour each day

[ ] 1–5 hours each day

[ ] More than 5 hours each day

48. Do you suffer from white finger syndrome/Raynaud's syndrome caused by excessive vibration (e.g., pneumatic hammers or drills)?

[ ] No

[ ] I don’t know

[ ] Yes

49. Have you ever worked for more than 1 year in a place where you had to raise your voice to make yourself heard by someone standing 1 m away from you?

[ ] No

[ ] Yes

If you answered “YES,” please also answer the following questions (48.1–48.10). If you have worked for different companies, or for the same company but in different workplaces (with a different noise level), please fill in the following questions for each “job.”

1st job (add additional copies for other jobs if necessary)

49.1. Please describe the job and give the name of the company ___________________________

49.2. Please describe the most important noise source(s) _________________________________

49.3. In which year did you start to do this job? ____________________________

49.4. How many years have you been doing this job? _____________________

49.5. What was the noise level (if you are aware of it) in dB? _________________

49.6. What was the noise dose (equivalent noise level if you are aware of it) in dBs? ___________

49.7. How many hours per day were you exposed to noise?

[ ] Less than 1 hour each day

[ ] 1–5 hours each day

[ ] More than 5 hours each day

49.8. Was this a constant loud noise or an impulse noise (i.e., noise with (ir)regular high peaks of sound, like hammering)?

[ ] Constant noise

[ ] Impulse noise

[ ] Both

49.9. Did you use noise protection?

[ ] Always

[ ] Most of the time

[ ] More than 50% of the time

[ ] Less than 50% of the time

[ ] Never

49.10. If any, which type of noise protection did you use?

[ ] Plugs

[ ] Earmuff

[ ] “Active” protection

[ ] Several

Background Information

50. What is your height? ___________cm (feet and inches)

51. What is your weight? ___________kg (stones and pounds)

52. Are you left or right handed?

[ ] left handed

[ ] right handed

53. Are you susceptible to sunburn?

[ ] very much

[ ] much

[ ] not very much

[ ] not at all

54. What is the color of your eyes?

[ ] very light blue or very light grey

[ ] blue

[ ] grey

[ ] green

[ ] light brown

[ ] dark brown

55. Have you ever smoked regularly?

[ ] No

[ ] Yes

If you answered “Yes,” please also answer the following questions (54.1–54.5).

55.1. At which age did you start smoking? __________

55.2. For how many years did you (have you) smoke(d) up to now? __________

55.3. Approximately how many cigarettes do (did) you smoke on average?

[ ] Less than 5 each day

[ ] 5–10 each day

[ ] 10–20 each day

[ ] More than 20 each day

55.4. Approximately how many cigars or cigarillos do (did) you smoke on average each day? __________

55.5. Approximately how much pipe tobacco (grams) do (did) you smoke each day? __________

56. Do you drink alcohol regularly (every week)?

[ ] No

[ ] Yes

If “YES,”

57.1. How many drinks do you have on average? (A small bottle of beer – 25cl, red or white wine – 12cl, or a small glass of spirits – 4cl counts as 1 drink).

[ ] Less than 1 drink each week

[ ] 1–5 drinks each week

[ ] 1–3 drinks each day

[ ] More than 3 drinks each day

Scoring Instructions

Please see Fransen et al. (2008) for a complete description of the statistical analysis used for these questions. Also, supplementary table 4 contains information on how the different variables were coded in this statistical analysis.

Protocol Name from Source:

Age-Related Hearing Impairment (ARHI) Questionnaire

Availability:

Publicly available

Personnel and Training Required

None

Equipment Needs

None

Requirements
Requirement CategoryRequired
Major equipment No
Specialized training No
Specialized requirements for biospecimen collection No
Average time of greater than 15 minutes in an unaffected individual No
Mode of Administration

Self-administered questionnaire

Life Stage:

Adult

Participants:

The Age-Related Hearing Impairment (ARHI) Questionnaire has been successfully used with an age range of 55–65 years old for unrelated samples, and 55–75 years old for family samples. The Speech and Hearing Working Group recommends that it could also be used for individuals over 75 years old and as young as 18 years old.

Selection Rationale

The Age-Related Hearing Impairment (ARHI) Questionnaire was chosen because it has been used in a large-scale multicenter study and provides excellent possibilities for data comparisons. Additionally, it contains questions on multiple topics such as family history and exposures to noise and toxic substances in a single questionnaire.

Language

Danish, Dutch, English, Finnish, German, Italian

Standards
StandardNameIDSource
Common Data Elements (CDE) Family Medical History Hearing Loss Assessment Description Text 3139286 CDE Browser
Logical Observation Identifiers Names and Codes (LOINC) Pers fam hx hearing loss proto 63008-7 LOINC
Common Data Elements (CDE) Family Medical History Hearing Loss Assessment Description Text 3139286 CDE Browser
Derived Variables

None

Process and Review

The Expert Review Panel #7 (ERP 7) reviewed the measures in the Speech and Hearing domain.

Guidance from the ERP 7 includes the following:

  • Minor changes to the specific instructions

Back-compatible: no changes to Data Dictionary

Previous version in Toolkit archive (link)

Source

Fransen, E., Topsakal, V., Hendrickx, J., Van Laer, L., Huyghe, J. R., Van Eyken, E., Lemkens, N., Hannula, S., Maki-Tokko, E., Jensen, M., Demeester, K., Tropitzch, A., Bonaconsa, A., Mazzoli, M., Espeso, A., Verbruggen, K., Huyghe, J., Huygen, P.L., Kunst, S., Manninen, M., Diaz-Lacava, A., Steffens, M., Wienker, T. F., Pyykko, I., Cremers, C. W. R. J., Kremer, H., Dhooge, I., Stephens, D., Orzan, E., Pfister, M., Bille, M., Parving, A., Sorri, M., Van De Heyining, P., & Van Camp, G. (2008). Occupational noise, smoking, and a high body mass index are risk factors for age-related hearing impairment and moderate alcohol consumption is protective: A European population-based multicenter study. Journal of the Association for Research in Otolaryngology, 9, 264–276.

General References
Lin F. R., Niparko J. K., Ferrucci L. (2011). Hearing loss prevalence in the United States. Arch. Intern. Med. 171, 1851-1852.
Protocol ID:

201501

Variables:
Export Variables
Variable Name Variable IDVariable DescriptiondbGaP Mapping
PX201501_Family_History_Hearing_Loss_Alcohol
PX201501560000 Do you drink alcohol regularly (every week)? N/A
PX201501_Family_History_Hearing_Loss_Alcohol_Number_Drinks
PX201501560100 How many drinks do you have on average? (A more
small bottle of beer ÔøΩ 25cl, red or white wine ÔøΩ 12cl, or a small glass of spirits ÔøΩ 4cl counts as 1 drink). show less
N/A
PX201501_Family_History_Hearing_Loss_Allergy
PX201501340600 Do you suffer from allergies? N/A
PX201501_Family_History_Hearing_Loss_Aspirin
PX201501420000 Do you take aspirin on a daily basis for more
your heart or to dilute your blood? show less
N/A
PX201501_Family_History_Hearing_Loss_Background_Noise
PX201501020000 Do you find it very difficult to follow a more
conversation if there is background noise (e.g., TV, radio, children playing)? show less
N/A
PX201501_Family_History_Hearing_Loss_Bechets
PX201501351000 Do you suffer from bechet's syndrome? N/A
PX201501_Family_History_Hearing_Loss_Blood_Diseases
PX201501341200 Do you suffer from blood diseases? N/A
PX201501_Family_History_Hearing_Loss_Cancer_Leukemia
PX201501390000 Have you had cancer or leukemia? N/A
PX201501_Family_History_Hearing_Loss_Cancer_Leukemia_Desccribe
PX201501390100 Which kind of cancer or leukemia? N/A
PX201501_Family_History_Hearing_Loss_Carotid
PX201501300000 Have you ever had an operation on your more
carotid artery? show less
N/A
PX201501_Family_History_Hearing_Loss_Carotid_Year
PX201501300100 Write down in which year(s) approximately N/A
PX201501_Family_History_Hearing_Loss_Catheterization
PX201501280000 Have you ever had coronary artery catheterization? N/A
PX201501_Family_History_Hearing_Loss_Catheterization_Type
PX201501280100 What type of intervention(s) (e.g., stent, more
balloon dilatation)? show less
N/A
PX201501_Family_History_Hearing_Loss_Catheterization_Year
PX201501280200 In which year(s) approximately? N/A
PX201501_Family_History_Hearing_Loss_Cause
PX201501010401 Do you know the reason for your hearing more
difficulty? (If there is a separate cause for each of your ears, please note them accordingly). show less
N/A
PX201501_Family_History_Hearing_Loss_Cause_Describe
PX201501010402 Describe: N/A
PX201501_Family_History_Hearing_Loss_Chemotherapy
PX201501390200 Have you been treated with chemotherapy or more
other medication for this condition? show less
N/A
PX201501_Family_History_Hearing_Loss_Chemotherapy_Desccribe
PX201501390300 Please fill in which medication if you know it N/A
PX201501_Family_History_Hearing_Loss_Chemotherapy_Year
PX201501390400 In which year(s) more
approximately?______________________ show less
N/A
PX201501_Family_History_Hearing_Loss_Children_Hearing_Problem
PX201501190001 Do you have any children with hearing more
difficulties? show less
N/A
PX201501_Family_History_Hearing_Loss_Children_Hearing_Problem_Number
PX201501190002 How many of your children have hearing more
difficulties? show less
N/A
PX201501_Family_History_Hearing_Loss_Children_Normal_Hearing
PX201501180001 Do you have any children with normal hearing? N/A
PX201501_Family_History_Hearing_Loss_Children_Normal_Hearing_Number
PX201501180002 How many of your children have normal hearing? N/A
PX201501_Family_History_Hearing_Loss_Child_Hearing_Problem_Age_Started_1
PX201501190103 Child with hearing difficulties: Age at more
onset of hearing difficulties show less
N/A
PX201501_Family_History_Hearing_Loss_Child_Hearing_Problem_Age_Started_2
PX201501190203 Child with hearing difficulties: Age at more
onset of hearing difficulties show less
N/A
PX201501_Family_History_Hearing_Loss_Child_Hearing_Problem_Age_Started_3
PX201501190303 Child with hearing difficulties: Age at more
onset of hearing difficulties show less
N/A
PX201501_Family_History_Hearing_Loss_Child_Hearing_Problem_Age_Started_4
PX201501190403 Child with hearing difficulties: Age at more
onset of hearing difficulties show less
N/A
PX201501_Family_History_Hearing_Loss_Child_Hearing_Problem_Birth_Year_1
PX201501190102 Child with hearing difficulties: Year of birth N/A
PX201501_Family_History_Hearing_Loss_Child_Hearing_Problem_Birth_Year_2
PX201501190202 Child with hearing difficulties: Year of birth N/A
PX201501_Family_History_Hearing_Loss_Child_Hearing_Problem_Birth_Year_3
PX201501190302 Child with hearing difficulties: Year of birth N/A
PX201501_Family_History_Hearing_Loss_Child_Hearing_Problem_Birth_Year_4
PX201501190402 Child with hearing difficulties: Year of birth N/A
PX201501_Family_History_Hearing_Loss_Child_Hearing_Problem_Cause_1
PX201501190104 Child with hearing difficulties: Cause of more
hearing difficulties (if known) show less
N/A
PX201501_Family_History_Hearing_Loss_Child_Hearing_Problem_Cause_2
PX201501190204 Child with hearing difficulties: Cause of more
hearing difficulties (if known) show less
N/A
PX201501_Family_History_Hearing_Loss_Child_Hearing_Problem_Cause_3
PX201501190304 Child with hearing difficulties: Cause of more
hearing difficulties (if known) show less
N/A
PX201501_Family_History_Hearing_Loss_Child_Hearing_Problem_Cause_4
PX201501190404 Child with hearing difficulties: Cause of more
hearing difficulties (if known) show less
N/A
PX201501_Family_History_Hearing_Loss_Child_Hearing_Problem_Sex_1
PX201501190101 Child with hearing difficulties: Sex N/A
PX201501_Family_History_Hearing_Loss_Child_Hearing_Problem_Sex_2
PX201501190201 Child with hearing difficulties: Sex N/A
PX201501_Family_History_Hearing_Loss_Child_Hearing_Problem_Sex_3
PX201501190301 Child with hearing difficulties: Sex N/A
PX201501_Family_History_Hearing_Loss_Child_Hearing_Problem_Sex_4
PX201501190401 Child with hearing difficulties: Sex N/A
PX201501_Family_History_Hearing_Loss_Circulation
PX201501320000 Do you have other problems with your heart more
or circulation? show less
N/A
PX201501_Family_History_Hearing_Loss_Circulation_Type
PX201501320100 Please write down which problems N/A
PX201501_Family_History_Hearing_Loss_Claudication
PX201501310000 Do you suffer from intermittent more
claudication? (This is if you can't walk more than 200 metres, because you get cramps in your legs, and when you stand still for a moment the pain gets better) show less
N/A
PX201501_Family_History_Hearing_Loss_Cogans
PX201501350900 Do you suffer from Cogan's syndrome? N/A
PX201501_Family_History_Hearing_Loss_Describe_Disease
PX201501341400 Please describe your disease(s): N/A
PX201501_Family_History_Hearing_Loss_Diabetes
PX201501330000 Do you suffer from diabetes? N/A
PX201501_Family_History_Hearing_Loss_Diabetes_Insulin
PX201501330100 Do you need insulin? N/A
PX201501_Family_History_Hearing_Loss_Difficulty_Hearing
PX201501010000 Do you have any difficulty with your hearing? N/A
PX201501_Family_History_Hearing_Loss_Discharge
PX201501070000 Have you ever had discharge of blood or pus, more
or smelly discharge (not wax) from either ear? show less
N/A
PX201501_Family_History_Hearing_Loss_Dizziness
PX201501090000 Have you ever suffered from attacks of more
dizziness in which things seem to spin around you? show less
N/A
PX201501_Family_History_Hearing_Loss_Ear_Disease
PX201501060000 Have you ever had an ear disease that has more
caused your hearing to get worse? show less
N/A
PX201501_Family_History_Hearing_Loss_Ear_Operation_Type_1
PX201501080101 Write down what type of operation, or why more
the operation was performed show less
N/A
PX201501_Family_History_Hearing_Loss_Ear_Operation_Type_2
PX201501080201 Write down what type of operation, or why more
the operation was performed show less
N/A
PX201501_Family_History_Hearing_Loss_Ear_Operation_Type_3
PX201501080301 Write down what type of operation, or why more
the operation was performed show less
N/A
PX201501_Family_History_Hearing_Loss_Ear_Operation_Type_4
PX201501080401 Write down what type of operation, or why more
the operation was performed show less
N/A
PX201501_Family_History_Hearing_Loss_Ear_Operation_Which_Ear_1
PX201501080102 Which ear? N/A
PX201501_Family_History_Hearing_Loss_Ear_Operation_Which_Ear_2
PX201501080202 Which ear? N/A
PX201501_Family_History_Hearing_Loss_Ear_Operation_Which_Ear_3
PX201501080302 Which ear? N/A
PX201501_Family_History_Hearing_Loss_Ear_Operation_Which_Ear_4
PX201501080402 Which ear? N/A
PX201501_Family_History_Hearing_Loss_Ear_Operation_Year_1
PX201501080103 Which year? (approximately) N/A
PX201501_Family_History_Hearing_Loss_Ear_Operation_Year_2
PX201501080203 Which year? (approximately) N/A
PX201501_Family_History_Hearing_Loss_Ear_Operation_Year_3
PX201501080303 Which year? (approximately) N/A
PX201501_Family_History_Hearing_Loss_Ear_Operation_Year_4
PX201501080403 Which year? (approximately) N/A
PX201501_Family_History_Hearing_Loss_Epilepsy
PX201501340400 Do you suffer from epilepsy? N/A
PX201501_Family_History_Hearing_Loss_Eye_Color
PX201501540000 What is the color of your eyes? N/A
PX201501_Family_History_Hearing_Loss_Father_Hearing_Problem
PX201501140000 As far as you know, does/did your father more
have hearing problems? show less
N/A
PX201501_Family_History_Hearing_Loss_Father_Hearing_Problem_Age_Of_Death
PX201501150000 If he is dead, how old was he when he died? N/A
PX201501_Family_History_Hearing_Loss_Father_Hearing_Problem_Age_Started
PX201501140300 At what age did his hearing problems start? N/A
PX201501_Family_History_Hearing_Loss_Father_Hearing_Problem_Birth_Year
PX201501140100 What was his year of birth? N/A
PX201501_Family_History_Hearing_Loss_Father_Hearing_Problem_Cause
PX201501140400 What is/was the cause of his hearing problem more
(if known)? show less
N/A
PX201501_Family_History_Hearing_Loss_Father_Hearing_Probles_Occupation
PX201501140200 What was his occupation? N/A
PX201501_Family_History_Hearing_Loss_Fired_Gun
PX201501440000 Have you ever fired a gun? N/A
PX201501_Family_History_Hearing_Loss_First_Noticed
PX201501010200 At what age did you first notice a hearing more
difficulty? show less
N/A
PX201501_Family_History_Hearing_Loss_Fullness
PX201501040000 Do you sometimes feel a fullness or blockage more
in your ears? show less
N/A
PX201501_Family_History_Hearing_Loss_Handedness
PX201501520000 Are you left or right handed? N/A
PX201501_Family_History_Hearing_Loss_Hashimoto
PX201501350800 Do you suffer from Hashimoto thyroidosis? N/A
PX201501_Family_History_Hearing_Loss_Heart_Attack
PX201501260000 Have you ever had a heart attack? N/A
PX201501_Family_History_Hearing_Loss_Heart_Attack_Year
PX201501260100 Write down in which year(s) approximately N/A
PX201501_Family_History_Hearing_Loss_Heart_Surgery
PX201501270000 Have you ever had heart surgery? N/A
PX201501_Family_History_Hearing_Loss_Heart_Surgery_Type
PX201501270100 What operation(s)? (Please describe) N/A
PX201501_Family_History_Hearing_Loss_Heart_Surgery_Year
PX201501270200 In which year(s) approximately? N/A
PX201501_Family_History_Hearing_Loss_Heavy_Weapon_Ear_Protection
PX201501440202 Did you use ear protection? (Heavy weapons more
(artillery/bazookas)) show less
N/A
PX201501_Family_History_Hearing_Loss_Heavy_Weapon_Ear_Protection_Type
PX201501440203 If any, which type of ear protection did you more
use? (Heavy weapons (artillery/bazookas)) show less
N/A
PX201501_Family_History_Hearing_Loss_Heavy_Weapon_Number_of_Shots
PX201501440201 Estimate the total number of shots fired more
(Heavy weapons (artillery/bazookas)) show less
N/A
PX201501_Family_History_Hearing_Loss_Height
PX201501500000 What is your height? N/A
PX201501_Family_History_Hearing_Loss_How_Long
PX201501420100 How long have you been taking aspirin so far? N/A
PX201501_Family_History_Hearing_Loss_How_Quickly
PX201501010300 How quickly did your hearing difficulty develop? N/A
PX201501_Family_History_Hearing_Loss_IBD
PX201501350200 Do you suffer from inflammatory bowel more
disease (Crohn's disease/colitis ulcerosa)? show less
N/A
PX201501_Family_History_Hearing_Loss_Infection
PX201501380000 Have you ever been treated for a serious more
infection with an antibiotic (other than penicillin) which was administered by injection/drip for a week or more? show less
N/A
PX201501_Family_History_Hearing_Loss_Infection_Desccribe
PX201501380100 for what sort of infections did you receive more
these antibiotics? show less
N/A
PX201501_Family_History_Hearing_Loss_Infection_Year
PX201501380200 In which year(s) more
approximately?______________________ show less
N/A
PX201501_Family_History_Hearing_Loss_Job_Exposure_Hours_1
PX201501490700 How many hours per day were you exposed to noise? N/A
PX201501_Family_History_Hearing_Loss_Job_Name_1
PX201501490100 Please describe the job and give the name of more
the company show less
N/A
PX201501_Family_History_Hearing_Loss_Job_Noise_Constant_1
PX201501490800 Was this a constant loud noise or an impulse more
noise (i.e., noise with (ir)regular high peaks of sound, like hammering)? show less
N/A
PX201501_Family_History_Hearing_Loss_Job_Noise_Dose_1
PX201501490600 What was the noise dose (equivalent noise more
level if you are aware of it) in dBs? show less
N/A
PX201501_Family_History_Hearing_Loss_Job_Noise_Level_1
PX201501490500 What was the noise level (if you are aware more
of it) in dB? show less
N/A
PX201501_Family_History_Hearing_Loss_Job_Noise_Protection_1
PX201501490900 Did you use noise protection? N/A
PX201501_Family_History_Hearing_Loss_Job_Noise_Protection_Type_1
PX201501491000 If any, which type of noise protection did more
you use? show less
N/A
PX201501_Family_History_Hearing_Loss_Job_Noise_Source_1
PX201501490200 Please describe the most important noise more
source(s) show less
N/A
PX201501_Family_History_Hearing_Loss_Job_Years_On_Job_1
PX201501490400 How many years have you been doing this job? N/A
PX201501_Family_History_Hearing_Loss_Job_Year_Started_1
PX201501490300 In which year did you start to do this job? N/A
PX201501_Family_History_Hearing_Loss_Kidney_Diseases
PX201501340800 Do you suffer from kidney diseases? N/A
PX201501_Family_History_Hearing_Loss_Light_Weapon_Ear_Protection
PX201501440102 Did you use ear protection? (Light weapons more
(rifles/shotguns)) show less
N/A
PX201501_Family_History_Hearing_Loss_Light_Weapon_Ear_Protection_Type
PX201501440103 If any, which type of ear protection did you more
use? (Light weapons (rifles/shotguns)) show less
N/A
PX201501_Family_History_Hearing_Loss_Light_Weapon_Number_of_Shots
PX201501440101 Estimate the total number of shots fired more
(Light weapons (rifles/shotguns)) show less
N/A
PX201501_Family_History_Hearing_Loss_Liver_Diseases
PX201501340900 Do you suffer from liver diseases? N/A
PX201501_Family_History_Hearing_Loss_Loud_Sounds
PX201501030000 Are you particularly sensitive to loud sounds? N/A
PX201501_Family_History_Hearing_Loss_Loud_Sound_Exposure
PX201501450000 During your leisure time, are you/have you more
been regularly (more than once a week) exposed to loud sound or noise (so that you have to shout to make yourself heard by someone who was more than 1 m away from you)? show less
N/A
PX201501_Family_History_Hearing_Loss_Loud_Sound_Hours
PX201501450300 How many hours per week have you been more
exposed to this loud sound? show less
N/A
PX201501_Family_History_Hearing_Loss_Loud_Sound_Protection
PX201501450400 Did you use ear protection? N/A
PX201501_Family_History_Hearing_Loss_Loud_Sound_Protection_Type
PX201501450500 If any, which type of ear protection did you use? N/A
PX201501_Family_History_Hearing_Loss_Loud_Sound_Type
PX201501450100 What kind of loud sound? N/A
PX201501_Family_History_Hearing_Loss_Loud_Sound_Years
PX201501450200 For how many years have you been exposed to more
this loud sound? show less
N/A
PX201501_Family_History_Hearing_Loss_Lung_Problems
PX201501340500 Do you suffer from lung problems? N/A
PX201501_Family_History_Hearing_Loss_Lupus
PX201501350300 Do you suffer fromlupus erythematosus? N/A
PX201501_Family_History_Hearing_Loss_Maternal_Grandfather_Country
PX201501110101 Where did your mother's father (your more
maternal grandfather) originate from? Country: show less
N/A
PX201501_Family_History_Hearing_Loss_Maternal_Grandfather_Region
PX201501110102 Where did your mother's father (your more
maternal grandfather) originate from? Region: show less
N/A
PX201501_Family_History_Hearing_Loss_Maternal_Grandmother_Country
PX201501110201 Where did your mother's mother (your more
maternal grandmother) originate from? Country: show less
N/A
PX201501_Family_History_Hearing_Loss_Maternal_Grandmother_Region
PX201501110202 Where did your mother's mother (your more
maternal grandmother) originate from? Region: show less
N/A
PX201501_Family_History_Hearing_Loss_Medication0_Duration_1
PX201501431003 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Duration of treatment show less
N/A
PX201501_Family_History_Hearing_Loss_Medication0_Name_1
PX201501431001 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Name drug: show less
N/A
PX201501_Family_History_Hearing_Loss_Medication0_Reason_1
PX201501431002 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Medical reason: show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Duration_1
PX201501430103 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Duration of treatment show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Duration_2
PX201501430203 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Duration of treatment show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Duration_3
PX201501430303 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Duration of treatment show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Duration_4
PX201501430403 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Duration of treatment show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Duration_5
PX201501430503 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Duration of treatment show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Duration_6
PX201501430603 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Duration of treatment show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Duration_7
PX201501430703 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Duration of treatment show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Duration_8
PX201501430803 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Duration of treatment show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Duration_9
PX201501430903 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Duration of treatment show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Name_1
PX201501430101 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Name drug: show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Name_2
PX201501430201 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Name drug: show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Name_3
PX201501430301 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Name drug: show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Name_4
PX201501430401 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Name drug: show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Name_5
PX201501430501 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Name drug: show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Name_6
PX201501430601 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Name drug: show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Name_7
PX201501430701 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Name drug: show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Name_8
PX201501430801 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Name drug: show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Name_9
PX201501430901 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Name drug: show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Reason_1
PX201501430102 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Medical reason: show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Reason_2
PX201501430202 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Medical reason: show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Reason_3
PX201501430302 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Medical reason: show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Reason_4
PX201501430402 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Medical reason: show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Reason_5
PX201501430502 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Medical reason: show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Reason_6
PX201501430602 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Medical reason: show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Reason_7
PX201501430702 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Medical reason: show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Reason_8
PX201501430802 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Medical reason: show less
N/A
PX201501_Family_History_Hearing_Loss_Medication_Reason_9
PX201501430902 Please list all of the medication you have more
taken on a regular basis (for more than 3 months) in the last year or that you are taking now on a regular basis. Medical reason: show less
N/A
PX201501_Family_History_Hearing_Loss_Meningitis
PX201501230000 Have you ever suffered a hearing loss from more
meningitis or encephalitis? show less
N/A
PX201501_Family_History_Hearing_Loss_Meningitis_Year
PX201501230100 Write down in which year(s) approximately N/A
PX201501_Family_History_Hearing_Loss_Migraine
PX201501220000 Do you suffer from migraine? N/A
PX201501_Family_History_Hearing_Loss_Migraine_How_Often
PX201501220100 How often do you generally have attacks? N/A
PX201501_Family_History_Hearing_Loss_Mother_Hearing_Problem
PX201501120000 As far as you know, does/did your mother more
have hearing problems? show less
N/A
PX201501_Family_History_Hearing_Loss_Mother_Hearing_Problem_Age_Of_Death
PX201501130000 If she is dead, how old was she when she died? N/A
PX201501_Family_History_Hearing_Loss_Mother_Hearing_Problem_Age_Started
PX201501120300 At what age did her hearing problems start? N/A
PX201501_Family_History_Hearing_Loss_Mother_Hearing_Problem_Birth_Year
PX201501120100 What was her year of birth? N/A
PX201501_Family_History_Hearing_Loss_Mother_Hearing_Problem_Cause
PX201501120400 What is/was the cause of her hearing problem more
(if known)? show less
N/A
PX201501_Family_History_Hearing_Loss_Mother_Hearing_Problem_Occupation
PX201501120200 What was her occupation? N/A
PX201501_Family_History_Hearing_Loss_MS
PX201501340300 Do you suffer from Multiple sclerosis (MS)? N/A
PX201501_Family_History_Hearing_Loss_Nephritis
PX201501350700 Do you suffer from nephritis? N/A
PX201501_Family_History_Hearing_Loss_Occupation
PX201501460000 What is/was your job? N/A
PX201501_Family_History_Hearing_Loss_Operation
PX201501080000 Have you ever had an ear operation? N/A
PX201501_Family_History_Hearing_Loss_Osteoarthritis
PX201501340200 Do you suffer from osteoarthritis? N/A
PX201501_Family_History_Hearing_Loss_Osteoporosis
PX201501340100 Do you suffer from osteoporosis? N/A
PX201501_Family_History_Hearing_Loss_Other_Autoimmune
PX201501351100 Other autoimmune diseases: N/A
PX201501_Family_History_Hearing_Loss_Other_Health_Problems
PX201501370000 Do you have other serious health problems more
that are not covered by the previous questions? show less
N/A
PX201501_Family_History_Hearing_Loss_Other_Health_Problems_Desccribe
PX201501370100 Please describe these problems: N/A
PX201501_Family_History_Hearing_Loss_Other_Operations
PX201501360000 Have you ever had other operations (not more
covered by the previous questions)? show less
N/A
PX201501_Family_History_Hearing_Loss_Other_Operation_1
PX201501360101 Operation: N/A
PX201501_Family_History_Hearing_Loss_Other_Operation_2
PX201501360201 Operation: N/A
PX201501_Family_History_Hearing_Loss_Other_Operation_3
PX201501360301 Operation: N/A
PX201501_Family_History_Hearing_Loss_Other_Operation_4
PX201501360401 Operation: N/A
PX201501_Family_History_Hearing_Loss_Other_Operation_Year_1
PX201501360102 Year: N/A
PX201501_Family_History_Hearing_Loss_Other_Operation_Year_2
PX201501360202 Year: N/A
PX201501_Family_History_Hearing_Loss_Other_Operation_Year_3
PX201501360302 Year: N/A
PX201501_Family_History_Hearing_Loss_Other_Operation_Year_4
PX201501360402 Year: N/A
PX201501_Family_History_Hearing_Loss_Painkillers
PX201501410000 On average how often do you take painkillers? N/A
PX201501_Family_History_Hearing_Loss_Paternal_Grandfather_Country
PX201501110301 Where did your father's father (your more
paternal grandfather) originate from? Country: show less
N/A
PX201501_Family_History_Hearing_Loss_Paternal_Grandfather_Region
PX201501110302 Where did your father's father (your more
paternal grandfather) originate from? Region: show less
N/A
PX201501_Family_History_Hearing_Loss_Paternal_Grandmother_Country
PX201501110401 Where did your father's mother (your more
paternal grandmother) originate from? Country: show less
N/A
PX201501_Family_History_Hearing_Loss_Paternal_Grandmother_Region
PX201501110402 Where did your father's mother (your more
paternal grandmother) originate from? Region: show less
N/A
PX201501_Family_History_Hearing_Loss_Psoriasis
PX201501350400 Do you suffer from psoriasis? N/A
PX201501_Family_History_Hearing_Loss_Psychiatric_Problems
PX201501341100 Do you suffer from psychiatric problems? N/A
PX201501_Family_History_Hearing_Loss_Radiotherapy
PX201501400000 Have you ever received radiotherapy to your more
head or neck for a tumour? show less
N/A
PX201501_Family_History_Hearing_Loss_Radiotherapy_Desccribe
PX201501400100 What kind of tumour(s)? N/A
PX201501_Family_History_Hearing_Loss_Radiotherapy_Year
PX201501400200 In which year(s) more
approximately?______________________ show less
N/A
PX201501_Family_History_Hearing_Loss_Raise_Voice
PX201501490000 Have you ever worked for more than 1 year in more
a place where you had to raise your voice to make yourself heard by someone standing 1 m away from you? show less
N/A
PX201501_Family_History_Hearing_Loss_Relatives_Participated
PX201501210100 Do you know if any of your relatives have more
already participated in this investigation? show less
N/A
PX201501_Family_History_Hearing_Loss_Relatives_Participated_Name
PX201501210200 Please write down the name of your relative more
and the relation between you show less
N/A
PX201501_Family_History_Hearing_Loss_Reynauds
PX201501480000 Do you suffer from white finger more
syndrome/Raynaud's syndrome caused by excessive vibration (e.g., pneumatic hammers or drills)? show less
N/A
PX201501_Family_History_Hearing_Loss_Rheumatism
PX201501350100 Do you suffer from rheumatoid_arthritis more
(rheumatism)? show less
N/A
PX201501_Family_History_Hearing_Loss_Siblings_Hearing_Problem
PX201501170001 Do you have any brothers or sisters with more
hearing difficulties? show less
N/A
PX201501_Family_History_Hearing_Loss_Siblings_Hearing_Problem_Number
PX201501170002 How many of your brothers/sisters have more
hearing difficulties? show less
N/A
PX201501_Family_History_Hearing_Loss_Siblings_Normal_Hearing
PX201501160001 Do you have any brothers or sisters with more
normal hearing? show less
N/A
PX201501_Family_History_Hearing_Loss_Siblings_Normal_Hearing_Number
PX201501160002 How many of your brothers/sisters have more
normal hearing? show less
N/A
PX201501_Family_History_Hearing_Loss_Sibling_Age_Started_1
PX201501170103 Brother/sister with hearing difficulties: more
Age at onset of hearing difficulties show less
N/A
PX201501_Family_History_Hearing_Loss_Sibling_Age_Started_2
PX201501170203 Brother/sister with hearing difficulties: more
Age at onset of hearing difficulties show less
N/A
PX201501_Family_History_Hearing_Loss_Sibling_Age_Started_3
PX201501170303 Brother/sister with hearing difficulties: more
Age at onset of hearing difficulties show less
N/A
PX201501_Family_History_Hearing_Loss_Sibling_Age_Started_4
PX201501170403 Brother/sister with hearing difficulties: more
Age at onset of hearing difficulties show less
N/A
PX201501_Family_History_Hearing_Loss_Sibling_Birth_Year_1
PX201501170102 Brother/sister with hearing difficulties: more
Year of birth show less
N/A
PX201501_Family_History_Hearing_Loss_Sibling_Birth_Year_2
PX201501170202 Brother/sister with hearing difficulties: more
Year of birth show less
N/A
PX201501_Family_History_Hearing_Loss_Sibling_Birth_Year_3
PX201501170302 Brother/sister with hearing difficulties: more
Year of birth show less
N/A
PX201501_Family_History_Hearing_Loss_Sibling_Birth_Year_4
PX201501170402 Brother/sister with hearing difficulties: more
Year of birth show less
N/A
PX201501_Family_History_Hearing_Loss_Sibling_Cause_1
PX201501170104 Brother/sister with hearing difficulties: more
Cause of hearing difficulties (if known) show less
N/A
PX201501_Family_History_Hearing_Loss_Sibling_Cause_2
PX201501170204 Brother/sister with hearing difficulties: more
Cause of hearing difficulties (if known) show less
N/A
PX201501_Family_History_Hearing_Loss_Sibling_Cause_3
PX201501170304 Brother/sister with hearing difficulties: more
Cause of hearing difficulties (if known) show less
N/A
PX201501_Family_History_Hearing_Loss_Sibling_Cause_4
PX201501170404 Brother/sister with hearing difficulties: more
Cause of hearing difficulties (if known) show less
N/A
PX201501_Family_History_Hearing_Loss_Sibling_Sex_1
PX201501170101 Brother/sister with hearing difficulties: Sex N/A
PX201501_Family_History_Hearing_Loss_Sibling_Sex_2
PX201501170201 Brother/sister with hearing difficulties: Sex N/A
PX201501_Family_History_Hearing_Loss_Sibling_Sex_3
PX201501170301 Brother/sister with hearing difficulties: Sex N/A
PX201501_Family_History_Hearing_Loss_Sibling_Sex_4
PX201501170401 Brother/sister with hearing difficulties: Sex N/A
PX201501_Family_History_Hearing_Loss_Skin_Diseases
PX201501341000 Do you suffer from skin diseases? N/A
PX201501_Family_History_Hearing_Loss_Smoker
PX201501550000 Have you ever smoked regularly? N/A
PX201501_Family_History_Hearing_Loss_Smoker_Number_Cigarettes
PX201501550300 Approximately how many cigarettes do (did) more
you smoke on average? show less
N/A
PX201501_Family_History_Hearing_Loss_Smoker_Number_Cigars
PX201501550400 Approximately how many cigars or cigarillos more
do (did) you smoke on average each day? show less
N/A
PX201501_Family_History_Hearing_Loss_Smoker_Pipe
PX201501550500 Approximately how much pipe tobacco (grams) more
do (did) you smoke each day? show less
N/A
PX201501_Family_History_Hearing_Loss_Smoker_Started
PX201501550100 At which age did you start smoking? N/A
PX201501_Family_History_Hearing_Loss_Smoker_Years
PX201501550200 For how many years did you (have you) more
smoke(d) up to now? show less
N/A
PX201501_Family_History_Hearing_Loss_Solvent_Exposure
PX201501470000 Have you been exposed to solvents (e.g., more
thrichloroethylene, toluene, evaporations from paints or lacquers) for more than one year in one of your jobs? show less
N/A
PX201501_Family_History_Hearing_Loss_Solvent_Exposure_Hours
PX201501470400 For how many hours per day were you exposed more
to solvents? show less
N/A
PX201501_Family_History_Hearing_Loss_Solvent_Exposure_Start
PX201501470200 In which year did the solvent exposure start? N/A
PX201501_Family_History_Hearing_Loss_Solvent_Exposure_Type
PX201501470100 Which solvents? N/A
PX201501_Family_History_Hearing_Loss_Solvent_Exposure_Years
PX201501470300 For how many years were you exposed to solvents? N/A
PX201501_Family_History_Hearing_Loss_Stomach_Diseases
PX201501340700 Do you suffer from diseases of the stomach more
or intestines? show less
N/A
PX201501_Family_History_Hearing_Loss_Stroke
PX201501290000 Have you ever had a stroke? N/A
PX201501_Family_History_Hearing_Loss_Stroke_Year
PX201501290100 Write down in which year(s) approximately N/A
PX201501_Family_History_Hearing_Loss_Sunburn
PX201501530000 Are you susceptible to sunburn? N/A
PX201501_Family_History_Hearing_Loss_Thyroid_Diseases
PX201501341300 Do you suffer from diseases of the thyroid gland? N/A
PX201501_Family_History_Hearing_Loss_Tinnitus
PX201501050000 Nowadays, do you ever get noises in your more
head or ears (tinnitus) which usually last longer than five minutes? show less
N/A
PX201501_Family_History_Hearing_Loss_Uncles_Aunts_Hearing_Problems
PX201501200000 Do you have uncles, aunts, cousins, nephews, more
or nieces with hearing difficulties? show less
N/A
PX201501_Family_History_Hearing_Loss_Unconscious
PX201501250000 Have you ever been knocked unconscious more
(e.g., in a traffic accident, contact sport, a fight or after a fall)? show less
N/A
PX201501_Family_History_Hearing_Loss_Unconscious_Year
PX201501250100 Write down in which year(s) approximately N/A
PX201501_Family_History_Hearing_Loss_Unsteady
PX201501100000 Do you feel unsteady when walking in the dark? N/A
PX201501_Family_History_Hearing_Loss_Vary
PX201501010500 Does your hearing vary from day to day? N/A
PX201501_Family_History_Hearing_Loss_Vasculitis
PX201501350600 Do you suffer from vasculitis? N/A
PX201501_Family_History_Hearing_Loss_Wegeners
PX201501350500 Do you suffer from Wegener's granulomatosis? N/A
PX201501_Family_History_Hearing_Loss_Weight
PX201501510000 What is your weight? N/A
PX201501_Family_History_Hearing_Loss_Which_Ear
PX201501010100 In which ear(s) do you have a hearing difficulty? N/A
PX201501_Family_History_Hearing_Loss_Whiplash
PX201501240000 Have you ever had a whiplash injury? N/A
PX201501_Family_History_Hearing_Loss_Whiplash_Year
PX201501240100 Write down in which year(s) approximately N/A
Speech, Language and Hearing
Measure Name:

Personal and Family History of Hearing Loss

Release Date:

October 8, 2010

Definition

This measure is a questionnaire to assess risk factors related to hearing loss.

Purpose

This measure can be used to assess familial, environmental, and other risk factors related to hearing loss.

Keywords

Family history, clinical history, exposure history, Age-Related Hearing Impairment Questionnaire, ARHI, hearing impairment, hearing difficulty, noise, ear disease, balance, operation, surgery, exposure, tinnitus, risk factors, speech and hearing