Voorbeeld vragenlijst

 

Verwijzer:

o   Audioloog

o   KNO-arts

o   Anders……….

 

 

Gehoorverlies opgemerkt door:

o   Neonatale gehoorscreening

o   Ouders/ omgeving

o   School

o   Anders……….

 

 

Eerste symptomen op de leeftijd:……….jaar/maanden

 

 

Reden van verwijzing:

o   Diagnose stelling

o   Genetisch advies

o   Anders………………

 

 

 

AD

Gemiddeld verlies (500-4000Hz):

Air-bone-gab (gemid 500-4000Hz):

AS

Gemiddeld verlies (500-4000Hz):

Air-bone-gab (gemid 500-4000Hz):

 

 

 

Otologische anamnese:

Gehoorverlies in combinatie met:

Otalgie                                                                                                                                              ja/nee

Otorrhoe                                                                                                                                                         ja/nee

Vertigo                                                                                                                                              ja/nee

Tinnitus                                                                                                                                                            ja/nee

        Anders……………...............................................................................................                                                                                                                                  

Otologische voorgeschiedenis:

(Recidiverende) acute otitiden                                                                               ja/nee

 

 

OME                                                                                                                                                   ja/nee

 

KNO operaties?                                                                                                                             ja/nee

                Trommelvlies buisjes                                                                                                   ja/nee

                Adenotomie                                                                                                                   ja/nee

Tonsillectomie                                                                                                                               ja/nee

                Anders……………………….…………………………………………………………………………………………………

 

 

Graviditeit/partus               G…/P…./A….

Complicaties voorgaande zwangerschappen                                                                    ja/nee

Ja, namelijk ....................................................................

 

graviditeit

Amenorrhoeduur                                                                                                         ……weken          

Complicaties graviditeit patiënt                                                                                              ja/nee

Infectie / koorts gehad?                                                                                                            ja/nee

                Periode: ...................................................................

Medicatie gebruikt? (ototoxisch)                                                                                          ja/nee

                Periode: ...................................................................

Roken                                                                                                                                                ja/nee

Alcohol                                                                                                                                              ja/nee

Overig                                                                                                                                               ja/nee

 

  partus

locatie partus                                                                                  thuis/ ziekenhuis/ ziekenhuis poliklinisch

indicatie klinisch partus                                                               maternale / kinderlijke indicatie namelijk.......................................................................................................

 

Geboorte gewicht                                                                                                        …………gram

Apgar score                                                                                                                                     /

 

 

Postnataal/Neonataal

Asfyxie/hypoxie/blauwzien                                                                                                     ja/nee

                Behandeling (>24 uur couveuze of beademing)                                              ja/nee

                                                                              

Icterus/geelzien                                                                                                                            ja/nee

                Behandeling                                                                     fototherapie/wisseltransfusie

 

Postpartum antibiotica                                                                                               ja/nee

 

 

Ontwikkeling

Motorische ontwikkeling?                                                                         normaal/ abnormaal

                                                                                                                                                            

Therapie gehad                                                                                                                             ja/nee

Leeftijd loslopen                                                                                                                   ……..maanden

 

Spraak-/taalontwikkeling:                                                                                  normaal/ abnormaal

Verschijnselen ....................................................................

Logopedische behandeling                                                                                                      ja/nee

 

 

Medische voorgeschiedenis

Opnamen                                                                                                                                        ja/nee

....................................................................

 

Operatie                                                                                                                                           ja/nee

....................................................................

 

Ernstige infecties                                                                                                                          ja/nee ....................................................................                  

 

(Hoofd)traumata/ongeval                                                                                                        ja/nee

....................................................................

 

Bekend met andere ziekten                                                                                                    ja/nee

Zo ja, welke?................................................................................................

 

 

Ernstige infectie cq sepsis                                                                                         ja/nee

......................................................................................

 

                Meningitis                                                                                                                        ja/nee

.....................................................................................

 

Epilepsie/ neurologische stoornissen                                                                   ja/nee

                               .....................................................................................

 

 

                Nierafwijkingen                                                                                                             ja/nee

                               ....................................................................................

 

                Schildklierafwijkingen                                                                                                 ja/nee

                               ......................................................................................

 

                Hartafwijkingen                                                                                                             ja/nee

                               .....................................................................................

 

                Visusklachten (waaronder: retinopathie/nachtblindheid,

hoge myopie,ablatio retina)                                                                     ja/nee

.....................................................................................

               

Heterochromie                                                                                                              ja/nee

                               ………………………………………………………………………………….

 

                Dystopia canthorum                                                                                                    ja/nee

                               …………………………………………………………………………….

 

                Dacryostenose                                                                                               ja/nee

                               ....................................................................................

 

 

Pigmentafwijkingen/ witte haarlok                                                                       ja/nee

                               .....................................................................................

 

 

                Ectodermale verschijnselen (huid, haren, nagels, transpiratie) ja/nee

.....................................................................................

 

 

                Fracturen                                                                                                                         ja/nee

                               ……………………………………………………………………………            

 

                Hyperlaxiteit                                                                                                                   ja/nee

                               …………………………………………………………………………….

 

                Schisis   - lip/kaak/verhemelte                                                                                 ja/nee

…………………………………………………………………………….

 

 

 

Huidig medicatiegebruik                                                                                                            ja/nee

                               .....................................................................................           

 

Medicatiegebruik in verleden                                                                                                 ja/nee

                               .....................................................................................

 

 

 

Familie anamnese

Slechthorendheid                                                                                                                                                 ja/nee

 

Type slechthorendheid                                                                    aangeboren/verworden       

Oorzaak/diagnose bekend                                                                                                       ja/nee                  ...................................................................

Aangedane personen ...................................................................

 

Schildklierafwijkingen                                                                                                                 ja/nee

                Aangedane personen...................................................................

 

Hartafwijkingen                                                                                                                            ja/nee

                Aangedane personen ...................................................................

 

Epilepsie/ neurologische stoornissen                                                                                  ja/nee

                Aangedane personen...................................................................

 

(Ernstige) visusafwijkingen?                                                                                                    ja/nee

                Aangedane personen   ..................................................................

 

Syndromale aandoening?                                                                                                         ja/nee

                Aangedane personen ...................................................................

 

Aangeboren/lichamelijke afwijkingen?

(waaronder: oogheelkundige problemen,                                         ledemaatsafwijkingen, ectodermale verschijnselen)                                               ja/nee

Aangedane personen   ...................................................................

 

Wegrakingen/syncope of acute hartdood?                                                                       ja/nee

Aangedane personen ...................................................................

 

Heterochromie irides?                                                                                                               ja/nee

Aangedane personen   ...................................................................

 

Pigmentafwijkingen/depigmentatie      /witte haarlok                                                  ja/nee

                Aangedane personen   ...................................................................                                                                  

Leerproblemen                                                                                                                             ja/nee

                Aangedane personen   ...................................................................

                              

Consanguiniteit ouders                                                                                                              ja/nee

 

Stamboom