Form

You may want to check with others to obtain more information to complete this form. The more we know, the better we are able to verify the best genetic testing for your concern.

Describe the situation. Is this a manageable condition? Are there significant health issues and are they being managed?

Ex: as a baby, in childhood, later in life?

Ex: family planning, understanding disease progression, etc.

Ex: for CMV (cytomgalovirus) or meningitis?

To look for enlarged vestibular aqueduct?

Ex: external ear malformations, or report of internal ear malformations.

Such as cataracts, very wide set eyes, blindness, retinitis, significant surgery, etc. (aside from usual near sightedness or far sightedness).

cardiac abnormalies, fainting, sudden death, long q-t syndrome?

Thyroid problems, diabetes, gastrointestinal problems

Pigmentation defects of the skin, eyes or hair

birth defects including: cleft palate, facial abnormalities (dysmorphology), limb abnormalities, short stature, neurodevelopmental or neurobehavioral issues (includes delay, mental retardation and mental illness)?

Any of the conditions listed on this form, considering ALL questions?

Of hearing-loss affected individual or any relative with issues mentioned.

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Discussions with a genetic counselor as offered by Genetic Laboratories and Genetic Testing Companies serve to provide key information for the understanding of genetic testing, although pedigree intake and record review may be focused to the results of genetic testing. Although laboratory license and permit and genetic counselor certification and licensure where applicable, do not permit the practice of medicine, genetic counselors can provide explanation and direction to physicians and authorized medical professionals for the interpretation of the results of genetic testing. Genetic counselors, upon physician waiver and in collaboration with ordering clinicians, can provide counseling on genetic testing and the meaning of test results. Comprehensive genetic counseling may be available through physicians who can provide genetic counseling within the scope of their practices as they choose and through genetic counselors within the scope of their practice. Please note that patient management and genetic counseling surrounding on-going prenatal or any diagnostic testing is best handled by Physicians, Maternal/Fetal and Pediatric Genetics specialists, in conjunction with clinical services where they are available and in collaboration with genetic counselors and other genetic specialists.

1. Name

2. What is your relationship to the individual with hearing loss?

3. How old is the affected and how are they doing now?

4. When was onset of hearing loss suspected?

5. Does anyone else in the family have hearing loss? Who?

6. Please describe your concern or reason for seeking information?

7. Was infection testing done upon diagnosis of hearing loss?

8. Has temporal bone -computed tomography been done?

9. Has the affected individual or anyone had any genetic testing?

10. Did affected have low birth weight or require NICU ventilation?

11. Does the affected individual have renal (kidney) problems?

12. Does the affected individual have any obvious ear abnormalities?

13. Does the person with hearing loss have any eye abnormalies?

14. Is there a history in the affected or in the family of:

15. Is there a history in the affected or in the family of:

16. Is there a history in the affected or in the family of:

17. Is there a history in the affected or in the family of:

18. Does anyone else in the familly have any of:

19. List significant hospitalizations:

20. Verifier