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Protocol - Personal and Family History of Hearing Loss

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Protocol Name from Source:

This section will be completed when reviewed by an Expert Review Panel.

Availability:

Publicly available

Description:

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

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 cigarellos 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.

Personnel and Training Required

None

Equipment Needs

Respondents will need a copy of the questionnaire.

Requirements

Requirement CategoryRequired
Average time of greater than 15 minutes in an unaffected individualNo
Major equipmentNo
Specialized requirements for biospecimen collectionNo
Specialized trainingNo

Mode of Administration

Self-administered

Life Stage:

Adult

Specific Instructions:

None
Research Domain Information

Release Date:

October 20, 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.

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 Text3139286CDE Browser
Logical Observation Identifiers Names and Codes (LOINC)Pers fam hx hearing loss proto63008-7LOINC

Process and Review

This section will be completed when reviewed by an Expert Review Panel.

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

None

Protocol ID:

201501

Variables:

Export Variables
Variable NameVariable IDVariable DescriptionVersiondbGaP Mapping
PX201501_Coronary_Artery_Catheterization_YearPX201501280200In which year(s) approximately?4N/A
PX201501_StrokePX201501290000Have you ever had a stroke?4N/A
PX201501_Stroke_YearPX201501290100Have you ever had a stroke? (write down in which year(s) approximately4N/A
PX201501_Carotid_Artery_OperationPX201501300000Have you ever had an operation on your carotid artery?4N/A
PX201501_Carotid_Artery_Operation_YearPX201501300100Have you ever had an operation on your carotid artery? (write down in which year(s) approximately)4N/A
PX201501_Intermittent_ClaudicationPX201501310000Do 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)4N/A
PX201501_Other_Heart_ProblemsPX201501320000Do you have other problems with your heart or circulation?4N/A
PX201501_Other_Heart_Problems_DescribePX201501320100Do you have other problems with your heart or circulation? (please write down which problems)4N/A
PX201501_DiabetesPX201501330000Do you suffer from diabetes?4N/A
PX201501_Need_InsulinPX201501330100Do you need insulin?4Variable Mapping
PX201501_OsteoporosisPX201501340100Osteoporosis4N/A
PX201501_OsteoarthritisPX201501340200Osteoarthritis4N/A
PX201501_Multiple_SclerosisPX201501340300Multiple sclerosis (MS)4N/A
PX201501_EpilepsyPX201501340400Epilepsy4N/A
PX201501_Lung_ProblemsPX201501340500Lung problems4N/A
PX201501_AllergyPX201501340600Allergy4N/A
PX201501_Stomach_IntestinesPX201501340700Diseases of the stomach or intestines4N/A
PX201501_Kidney_DiseasePX201501340800Kidney diseases4N/A
PX201501_Liver_DiseasesPX201501340900Liver diseases4N/A
PX201501_Skin_DiseasesPX201501341000Skin diseases4N/A
PX201501_Psychiatric_ProblemsPX201501341100Psychiatric problems4N/A
PX201501_Blood_DiseasesPX201501341200Blood diseases4N/A
PX201501_Thyroid_DiseasesPX201501341300Diseases of the thyroid gland4N/A
PX201501_Describe_DiseasePX201501341400Please describe your disease(s):4N/A
PX201501_Rheumatoid_ArthritisPX201501350100Rheumatoid arthritis (rheumatism)4N/A
PX201501_Inflammatory_Bowel_DiseasePX201501350200Inflammatory bowel disease (Crohn's disease / colitis ulcerosa)4N/A
PX201501_LupusPX201501350300Lupus erythematosus4N/A
PX201501_PsoriasisPX201501350400Psoriasis4N/A
PX201501_Wegeners_GranulomatosisPX201501350500Wegener's granulomatosis4N/A
PX201501_VasculitisPX201501350600Vasculitis4N/A
PX201501_NephritisPX201501350700Nephritis4N/A
PX201501_Hashimoto_ThyroiditisPX201501350800Hashimoto thyroiditis4N/A
PX201501_Cogans_SyndromePX201501350900Cogan's syndrome4N/A
PX201501_Behcets_SyndromePX201501351000Behcet's syndrome4N/A
PX201501_Other_Autoimmune_DiseasesPX201501351100Other autoimmune diseases4N/A
PX201501_Other_OperationPX201501360000Have you ever had other operations (not covered by the previous questions)?4N/A
PX201501_Other_Operation1_TypePX201501360101Other operation 1 type4N/A
PX201501_Other_Operation1_YearPX201501360102Other operation 1 year4N/A
PX201501_Other_Operation2_TypePX201501360201Other operation 24N/A
PX201501_Other_Operation2_YearPX201501360202Other operation 2 year4N/A
PX201501_Other_Operation3_TypePX201501360301Other operation 34N/A
PX201501_Other_Operation3_YearPX201501360302Other operation 3 year4N/A
PX201501_Other_Operation4_TypePX201501360401Other operation 44N/A
PX201501_Other_Operation4_YearPX201501360402Other operation 4 year4N/A
PX201501_Other_Serious_Health_ProblemsPX201501370000Do you have other serious health problems that are not covered by the previous questions?4N/A
PX201501_Other_Serious_Health_Problems_DescribePX201501370100Please describe these problems:4N/A
PX201501_Antibiotic_DripPX201501380000Have 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?4N/A
PX201501_Antibiotic_Drip_InfectionPX201501380100If 'YES', for what sort of infections did you receive these antibiotics?4N/A
PX201501_Antibiotic_Drip_YearPX201501380200In which year(s) approximately?4N/A
PX201501_CancerPX201501390000Have you had cancer or leukaemia?4Variable Mapping
PX201501_Cancer_TypePX201501390100Which kind of cancer or leukaemia?4Variable Mapping
PX201501_Cancer_Chemotherapy_MedicationPX201501390200Have you been treated with chemotherapy or other medication for this condition?4N/A
PX201501_Cancer_Chemotherapy_Medication_TypePX201501390201Have you been treated with chemotherapy or other medication for this condition? If 'YES', with: ______ (please fill in which medication if you know it)4N/A
PX201501_Cancer_Chemotherapy_Medication_YearPX201501390202Have you been treated with chemotherapy or other medication for this condition? in __________ (in which year(s) approximately)4N/A
PX201501_Radiotherapy_TumorPX201501400000Have you ever received radiotherapy to your head or neck for a tumour?4N/A
PX201501_Radiotherapy_Tumor_TypePX201501400100Have you ever received radiotherapy to your head or neck for a tumour? What kind of tumour(s)?4N/A
PX201501_Radiotherapy_Tumor_YearPX201501400200Have you ever received radiotherapy to your head or neck for a tumour? In which year(s) approximately?4N/A
PX201501_Painkiller_FrequencyPX201501410000On average how often do you take painkillers?4N/A
PX201501_Daily_AspirinPX201501420000Do you take aspirin on a daily basis for your heart or to dilute your blood?4N/A
PX201501_Daily_Aspirin_How_LongPX201501420100Do you take aspirin on a daily basis for your heart or to dilute your blood? If 'YES', how long have you been taking aspirin so far?4N/A
PX201501_Regular_Medication1_NamePX201501430100Name drug4N/A
PX201501_Regular_Medication1_ReasonPX201501430200Medical reason:4N/A
PX201501_Regular_Medication1_DurationPX201501430300Duration of treatment4N/A
PX201501_Regular_Medication2_NamePX201501430400Name drug:4N/A
PX201501_Regular_Medication2_ReasonPX201501430500Medical reason:4N/A
PX201501_Regular_Medication2_DurationPX201501430600Duration of treatment4N/A
PX201501_Regular_Medication3_NamePX201501430700Name drug:4N/A
PX201501_Regular_Medication3_ReasonPX201501430800Medical reason:4N/A
PX201501_Regular_Medication3_DurationPX201501430900Duration of treatment4N/A
PX201501_Regular_Medication4_NamePX201501431000Name drug:4N/A
PX201501_Regular_Medication4_ReasonPX201501431100Medical reason:4N/A
PX201501_Regular_Medication4_DurationPX201501431200Duration of treatment4N/A
PX201501_Regular_Medication5_NamePX201501431300Name drug:4N/A
PX201501_Regular_Medication5_ReasonPX201501431400Medical reason:4N/A
PX201501_Regular_Medication5_DurationPX201501431500Duration of treatment4N/A
PX201501_Regular_Medication6_NamePX201501431600Name drug:4N/A
PX201501_Regular_Medication6_ReasonPX201501431700Please 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 Medical reason:4N/A
PX201501_Regular_Medication6_DurationPX201501431800Please 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 Duration of treatment4N/A
PX201501_Regular_Medication7_NamePX201501431900Name drug:4N/A
PX201501_Regular_Medication7_ReasonPX201501432000Medical reason:4N/A
PX201501_Regular_Medication7_DurationPX201501432100Duration of treatment4N/A
PX201501_Regular_Medication8_NamePX201501432200Name drug:4N/A
PX201501_Regular_Medication8_ReasonPX201501432300Medical reason:4N/A
PX201501_Regular_Medication8_DurationPX201501432400Duration of treatment4N/A
PX201501_Regular_Medication9_NamePX201501432500Name drug:4N/A
PX201501_Regular_Medication9_ReasonPX201501432600Medical reason:4N/A
PX201501_Regular_Medication9_DurationPX201501432700Duration of treatment4N/A
PX201501_Regular_Medication10_NamePX201501432800Name drug:4N/A
PX201501_Regular_Medication10_ReasonPX201501432900Medical reason:4N/A
PX201501_Regular_Medication10_DurationPX201501433000Duration of treatment4N/A
PX201501_Ever_Fired_GunPX201501440000Have you ever fired a gun?4N/A
PX201501_Light_Weapons_Number_ShotsPX201501440100Light weapons (rifles/shotguns). Estimate the total number of shots fired.4N/A
PX201501_Light_Weapons_Ear_ProtectionPX201501440200Light weapons (rifles/shotguns). Did you use ear protection?4N/A
PX201501_Light_Weapons_Ear_Protection_TypePX201501440300Light weapons (rifles/shotguns). If any, which type of ear protection did you use?4N/A
PX201501_Heavy_Weapons_Number_ShotsPX201501440400Heavy weapons (artillery/bazookas). Estimate the total number of shots fired.4N/A
PX201501_Heavy_Weapons_Ear_ProtectionPX201501440500Heavy weapons (artillery/bazookas). Did you use ear protection?4N/A
PX201501_Heavy_Weapons_Ear_Protection_TypePX201501440600Heavy weapons (artillery/bazookas). If any, which type of ear protection did you use?4N/A
PX201501_Leisure_Time_Loud_NoisePX201501450000During 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)?4N/A
PX201501_Leisure_Time_Loud_Noise_TypePX201501450100What kind of loud sound?4N/A
PX201501_Leisure_Time_Loud_Noise_YearsPX201501450200For how many years have you been exposed to this loud sound?4N/A
PX201501_Leisure_Time_Loud_Noise_HoursPerWeekPX201501450300How many hours per week have you been exposed to this loud sound?4N/A
PX201501_Leisure_Time_Loud_Noise_EarProtectionPX201501450400Did you use ear protection?4N/A
PX201501_Leisure_Time_Loud_Noise_EarProtectionTypePX201501450500If any, which type of ear protection did you use?4N/A
PX201501_OccupationPX201501460000What is/was your job?4N/A
PX201501_Occupational_Exposure_To_SolventsPX201501470000Have you been exposed to solvents (e.g., thrichloroethylene, toluene, evaporations from paints or lacquers) for more than one year in one of your jobs?4N/A
PX201501_Occupational_Exposure_To_Solvents_TypePX201501470100Which solvents?4N/A
PX201501_Occupational_Exposure_To_Solvents_StartPX201501470200In which year did the solvent exposure start?4N/A
PX201501_Occupational_Exposure_To_Solvents_YearsPX201501470300For how many years were you exposed to solvents?4N/A
PX201501_Occupational_Exposure_To_Solvents_HoursPerDayPX201501470400For how many hours per day were you exposed to solvents?4N/A
PX201501_White_Finger_SyndromePX201501480000Do you suffer from white finger syndrome/Raynaud's syndrome caused by excessive vibration (e.g., pneumatic hammers or drills)?4N/A
PX201501_Loud_Working_EnvironmentPX201501490000Have 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?4N/A
PX201501_Loud_Working_Environment_JobPX201501490100Please describe the job4N/A
PX201501_Loud_Working_Environment_CompanyPX201501490101Please give the name of the company4N/A
PX201501_Loud_Working_Environment_NoiseSourcePX201501490200Please describe the most important noise source(s)4N/A
PX201501_Loud_Working_Environment_StartPX201501490300In which year did you start to do this job?4N/A
PX201501_Loud_Working_Environment_YearsPX201501490400How many years have you been doing this job?4N/A
PX201501_Loud_Working_Environment_NoiseLevelPX201501490500What was the noise level (if you are aware of it) in dB?4N/A
PX201501_Loud_Working_Environment_NoiseDosePX201501490600What was the noise dose (equivalent noise level if you are aware of it) in dBs?4N/A
PX201501_Loud_Working_Environment_HoursPerDayPX201501490700How many hours per day were you exposed to noise?4N/A
PX201501_Loud_Working_Environment_Constant_ImpulsePX201501490800Was this a constant loud noise or an impulse noise (i.e., noise with (ir)regular high peaks of sound, like hammering)?4N/A
PX201501_Loud_Working_Environment_Use_NoiseProtectionPX201501490900Did you use noise protection?4N/A
PX201501_Loud_Working_Environment_NoiseProtection_TypePX201501491000If any, which type of noise protection did you use?4N/A
PX201501_HeightPX201501500000What is your height?4N/A
PX201501_Height_UnitsPX201501500100What is your height? Units4N/A
PX201501_WeightPX201501510000What is your weight?4Variable Mapping
PX201501_Weight_UnitsPX201501510100What is your weight? Units4Variable Mapping
PX201501_HandednessPX201501520000Are you left or right handed?4N/A
PX201501_Susceptible_To_SunburnPX201501530000Are you susceptible to sunburn?4N/A
PX201501_Eye_ColorPX201501540000What is the color of your eyes?4N/A
PX201501_Smoked_RegularlyPX201501550000Have you ever smoked regularly?4N/A
PX201501_Age_Started_SmokingPX201501550100At which age did you start smoking?4N/A
PX201501_Years_SmokedPX201501550200For how many years did you (have you) smoke(d) up to now?4N/A
PX201501_Average_Number_Cigarettes_SmokedPX201501550300Approximately how many cigarettes do (did) you smoke on average?4N/A
PX201501_Average_Number_CigarsPX201501550400Approximately how many cigars or cigarellos do (did) you smoke on average each day?4N/A
PX201501_Amount_Pipe_TobaccoPX201501550500Approximately how much pipe tobacco (grams) do (did) you smoke each day?4N/A
PX201501_Drink_Alcohol_RegularlyPX201501560000Do you drink alcohol regularly (every week)?4N/A
PX201501_Average_Number_DrinksPX201501570100How 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)4N/A
PX201501_Difficulty_HearingPX201501010000Do you have any difficulty with your hearing?4N/A
PX201501_Which_Ear_AffectedPX201501010100In which ear(s) do you have a hearing difficulty?4N/A
PX201501_Age_First_Noticed_Hearing_DifficultyPX201501010200At what age did you first notice a hearing difficulty?4N/A
PX201501_How_Quickly_Difficulty_DevelopedPX201501010300How quickly did your hearing difficulty develop?4N/A
PX201501_Reason_For_DifficultyPX201501010400Do you know the reason for your hearing difficulty? (if there is a separate cause for each of your ears, please note them accordingly)4N/A
PX201501_Reason_For_Difficulty_DescribePX201501010401Do you know the reason for your hearing difficulty? (if there is a separate cause for each of your ears, please note them accordingly) Describe:4N/A
PX201501_Hearing_Vary_Day_To_DayPX201501010500Does your hearing vary from day to day?4N/A
PX201501_Background_NoisePX201501020000Do you find it very difficult to follow a conversation if there is background noise (e.g. TV, radio, children playing)?4N/A
PX201501_Sensitive_Loud_SoundsPX201501030000Are you particularly sensitive to loud sounds?4N/A
PX201501_Fullness_In_EarsPX201501040000Do you sometimes feel a fullness or blockage in your ears?4N/A
PX201501_TinnitusPX201501050000Nowadays, do you ever get noises in your head or ears (tinnitus) which usually last longer than five minutes?4N/A
PX201501_Disease_Caused_Hearing_Get_WorsePX201501060000Have you ever had an ear disease that has caused your hearing to get worse?4N/A
PX201501_Ear_DischargePX201501070000Have you ever had discharge of blood or pus, or smelly discharge (not wax) from either ear?4N/A
PX201501_Ear_OperationPX201501080000Have you ever had an ear operation?4N/A
PX201501_EarOperation1_TypePX201501080101Write down what type of operation, or why the operation was performed4N/A
PX201501_EarOperation1_Which_EarPX201501080102Which ear?4N/A
PX201501_EarOperation1_YearPX201501080103Which year? (approximately)4N/A
PX201501_EarOperation2_TypePX201501080201Write down what type of operation, or why the operation was performed4N/A
PX201501_EarOperation2_Which_EarPX201501080202Which ear?4N/A
PX201501_EarOperation2_YearPX201501080203Which year? (approximately)4N/A
PX201501_EarOperation3_TypePX201501080301Write down what type of operation, or why the operation was performed4N/A
PX201501_EarOperation3_Which_EarPX201501080302Which ear?4N/A
PX201501_EarOperation3_YearPX201501080303Which year? (approximately)4N/A
PX201501_EarOperation4_TypePX201501080401Write down what type of operation, or why the operation was performed4N/A
PX201501_EarOperation4_Which_EarPX201501080402Which ear?4N/A
PX201501_EarOperation4_YearPX201501080403Which year? (approximately)4N/A
PX201501_DizzinessPX201501090000Have you ever suffered from attacks of dizziness in which things seem to spin around you?4N/A
PX201501_Unsteady_In_DarkPX201501100000Do you feel unsteady when walking in the dark?4N/A
PX201501_Mothers_Father_CountryPX201501110101Where did your mother's father (your maternal grandfather) originate from? Specify Country4N/A
PX201501_Mothers_Father_RegionPX201501110102Where did your mother's father (your maternal grandfather) originate from? Specify Region4N/A
PX201501_Mothers_Mother_CountryPX201501110201Where did your mother's mother (your maternal grandmother) originate from? Specify Country4N/A
PX201501_Mothers_Mother_RegionPX201501110202Where did your mother's mother (your maternal grandmother) originate from? Specify Region4N/A
PX201501_Fathers_Father_CountryPX201501110301Where did your father's father (your paternal grandfather) originate from? Specify Country4N/A
PX201501_Fathers_Father_RegionPX201501110302Where did your father's father (your paternal grandfather) originate from? Specify Region4N/A
PX201501_Fathers_Mother_CountryPX201501110401Where did your father's mother (your paternal grandmother) originate from? Specify Country4N/A
PX201501_Fathers_Mother_RegionPX201501110402Where did your father's mother (your paternal grandmother) originate from? Specify Region4N/A
PX201501_Mother_Have_Hearing_ProblemsPX201501120000As far as you know, does/did your mother have hearing problems?4N/A
PX201501_Mothers_Birth_YearPX201501120100What was her year of birth?4N/A
PX201501_Mothers_OccupationPX201501120200What was her occupation?4N/A
PX201501_Age_Mothers_Hearing_Problems_StartedPX201501120300At what age did her hearing problems start?4N/A
PX201501_Cause_Of_Mothers_Hearing_ProblemPX201501120400What is/was the cause of her hearing problem (if known)?4N/A
PX201501_Age_Mother_DiedPX201501130000If she is dead, how old was she when she died?4N/A
PX201501_Father_Have_Hearing_ProblemPX201501140000As far as you know does/did your father have hearing problems?4N/A
PX201501_Fathers_Birth_YearPX201501140100What was his year of birth?4N/A
PX201501_Fathers_OccupationPX201501140200What was his occupation?4N/A
PX201501_Age_Onset_Fathers_Hearing_ProblemPX201501140300At what age did his hearing problems start?4N/A
PX201501_Cause_Of_Fathers_Hearing_ProblemPX201501140400What is/was the cause of his hearing problems (if known)?4N/A
PX201501_Age_Father_DiedPX201501150000If he is dead, how old was he when he died?4N/A
PX201501_Siblings_With_Normal_HearingPX201501160000Do you have any brothers or sisters with normal hearing?4N/A
PX201501_Number_Siblings_With_Normal_HearingPX201501160100Do you have any brothers or sisters with normal hearing? (how many of your brothers/sisters have normal hearing?)4N/A
PX201501_Siblings_With_Hearing_DifficultiesPX201501170000Do you have any brothers or sisters with hearing difficulties?4N/A
PX201501_Number_Siblings_With_Hearing_DifficultiesPX201501170100Do you have any brothers or sisters with hearing difficulties? (how many of your brothers/sisters have hearing difficulties?)4N/A
PX201501_Sibling1_SexPX201501170101Sex4N/A
PX201501_Sibling1_Birth_YearPX201501170102Year of birth4N/A
PX201501_Sibling1_Age_Onset_Hearing_DifficultyPX201501170103Age at onset of hearing difficulties4N/A
PX201501_Sibling1_Cause_Of_Hearing_DifficultyPX201501170104Cause of hearing difficulties (if known)4N/A
PX201501_Sibling2_SexPX201501170201Sex4N/A
PX201501_Sibling2_Year_Of_BirthPX201501170202Year of birth4N/A
PX201501_Sibling2_Age_Onset_Hearing_DifficultyPX201501170203Age at onset of hearing difficulties4N/A
PX201501_Sibling2_Cause_Of_Hearing_DifficultyPX201501170204Cause of hearing difficulties (if known)4N/A
PX201501_Sibling3_SexPX201501170301Sex4N/A
PX201501_Sibling3_Birth_YearPX201501170302Year of birth4N/A
PX201501_Sibling3_Age_Onset_Hearing_DifficultyPX201501170303Age at onset of hearing difficulties4N/A
PX201501_Sibling3_Cause_Of_Hearing_DifficultyPX201501170304Cause of hearing difficulties (if known)4N/A
PX201501_Sibling4_SexPX201501170401Sex4N/A
PX201501_Sibling4_Birth_YearPX201501170402Year of birth4N/A
PX201501_Sibling4_Age_Onset_Hearing_DifficultyPX201501170403Age at onset of hearing difficulties4N/A
PX201501_Sibling4_Cause_Of_Hearing_DifficultyPX201501170404Cause of hearing difficulties (if known)4N/A
PX201501_Children_With_Normal_HearingPX201501180000Do you have any children with normal hearing?4N/A
PX201501_Children_With_Normal_Hearing_NumberPX201501180100Do you have any children with normal hearing? (how many of your children have normal hearing)4N/A
PX201501_Children_With_Hearing_DifficultyPX201501190000Do you have any children with hearing difficulties?4N/A
PX201501_Children_With_Hearing_Difficulty_NumberPX201501190100Do you have any children with hearing difficulties? (how many of your children have hearing difficulties?)4N/A
PX201501_Child1_SexPX201501190101Sex4N/A
PX201501_Child1_Birth_YearPX201501190102Year of birth4N/A
PX201501_Child1_Age_Onset_Hearing_DifficultyPX201501190103Age at onset of hearing difficulties4N/A
PX201501_Child1_Cause_Of_Hearing_DifficultyPX201501190104Cause of hearing difficulties (if known)4N/A
PX201501_Child2_SexPX201501190201Sex4N/A
PX201501_Child2_Birth_YearPX201501190202Year of birth4N/A
PX201501_Child2_Age_Onset_Hearing_DifficultyPX201501190203Age at onset of hearing difficulties4N/A
PX201501_Child2_Cause_Of_Hearing_DifficultyPX201501190204Cause of hearing difficulties (if known)4N/A
PX201501_Child3_SexPX201501190301Sex4N/A
PX201501_Child3_Birth_YearPX201501190302Year of birth4N/A
PX201501_Child3_Age_Onset_Hearing_DifficultyPX201501190303Age at onset of hearing difficulties4N/A
PX201501_Child3_Cause_Of_Hearing_DifficultyPX201501190304Cause of hearing difficulties (if known)4N/A
PX201501_Child4_SexPX201501190401Sex4N/A
PX201501_Child4_Birth_YearPX201501190402Year of birth4N/A
PX201501_Child4_Age_Onset_Hearing_DifficultyPX201501190403Age at onset of hearing difficulties4N/A
PX201501_Child4_Cause_Of_Hearing_DifficultyPX201501190404Cause of hearing difficulties (if known)4N/A
PX201501_Other_Relatives_With_Hearing_DifficultyPX201501200000Do you have uncles, aunts, cousins, nephews, or nieces with hearing difficulties?4N/A
PX201501_Other_Relatives_ParticipatedPX201501210000Do you know if any of your relatives have already participated in this investigation?4N/A
PX201501_Other_Relative_NamePX201501210100Do you know if any of your relatives have already participated in this investigation? (please write down the name of your relative and the relation between you)4N/A
PX201501_Other_Relative_RelationPX201501210200Do you know if any of your relatives have already participated in this investigation? (please write down the name of your relative and the relation between you)4N/A
PX201501_MigrainePX201501220000Do you suffer from migraine?4N/A
PX201501_Migraine_FrequencyPX201501220100How often do you generally have attacks?4N/A
PX201501_Hearing_Loss_Meningitis_EncephalitisPX201501230000Have you ever suffered a hearing loss from meningitis or encephalitis?4N/A
PX201501_Hearing_Loss_Meningitis_Encephalitis_YearPX201501230100Have you ever suffered a hearing loss from meningitis or encephalitis? (write down in which year(s) approximately)4N/A
PX201501_WhiplashPX201501240000Have you ever had a whiplash injury?4N/A
PX201501_Whiplash_YearPX201501240100Have you ever had a whiplash injury? (write down in which year(s) approximately)4N/A
PX201501_Knocked_UnconsciousPX201501250000Have you ever been knocked unconscious (e.g., in a traffic accident, contact sport, a fight or after a fall)?4N/A
PX201501_Knocked_Unconscious_YearPX201501250100Have you ever been knocked unconscious (e.g., in a traffic accident, contact sport, a fight or after a fall)? (write down in which year(s) approximately)4N/A
PX201501_Heart_AttackPX201501260000Have you ever had a heart attack?4N/A
PX201501_Heart_Attack_YearPX201501260100Have you ever had a heart attack? (write down in which year(s) approximately)4N/A
PX201501_Heart_SurgeryPX201501270000Have you ever had heart surgery?4N/A
PX201501_Heart_Surgery_TypePX201501270100What operation(s)? (Please describe)4N/A
PX201501_Heart_Surgery_YearPX201501270200In which year(s) approximately?4N/A
PX201501_Coronary_Artery_CatheterizationPX201501280000Have you ever had coronary artery catheterization?4N/A
PX201501_Coronary_Artery_Catheterization_InterventionPX201501280100What type of intervention(s) (e.g., stent, balloon dilatation)?4N/A