The Rockefeller University Study on the Genetics of Non-syndromic Hearing Loss

Family History Questionnaire

Name: Tel (H):
Address:
 Tel (W):
TTY:
E-mail:

Section 1

Instructions: In the first column you will find a list of family members (yourself, mother, sister, etc.). Select a proper family member (you can select any family member in any row except first two, which are reserve d for you and your spouse). In the second column please select the correct hearing status of the family member, Yes if the relative has hearing loss or deafness or No if you are not aware of the relative having a hearing loss or Don’t Know if the hearing status of the family member is unknown. Select Not Applicable in the lines you don't want to fill (when you already gave information about all family members, but there are still rows left in the table).

Please complete the following for all of your family members.

Family Member

Hearing loss or deafness
Yes No Don’t Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know
Not Applicable Yes No Don't Know

Section 2

Instructions: Please select Yes or No for the following questions.

1.Do you have any nieces or nephews (children of your sisters or brothers) who have a hearing loss? Not Applicable Yes No Don't Know
2a.Do any of your cousins on your mother's side of the family have a hearing loss? Not Applicable Yes No Don't Know
2b.Do any of your cousins on your father's side of the family have a hearing loss? Not Applicable Yes No Don't Know
3.Have you been told by a physician that your hearing loss is part of a syndrome? Yes No
3a.If Yes what is the name of the syndrome

Section 3

Instructions: Please list those blood relatives with hearing loss or deafness who were not included in section 1. List in relation to you, e.g. "My brother's daughter".

Section 4

If you wish to add more information, please do so below.

Consent:

Would you be willing to participate in a study on the genetics of hearing loss? Yes No