| Q1 |
Case information |
| Name (Do not write real name. Give initials, or use letters, e.g., A, B, C.) |
| Sex |
1. Male |
2. Female |
|
|
|
| Date of birth |
Showa |
A.D. |
|
|
|
| Q2 |
Cause of hearing disorder: |
| 1. Unclear |
2. Familial (hereditary) |
3.Disease after birth (name of disease: xx; age of onset: xx years old), |
4. Premature birth |
5. Disease affecting mother during pregnancy (name of disease) |
|
| Q3 |
Age underwent cochlear implantation: |
| Age |
( xx years and xx months old) |
| Operated side |
1. Right |
2. Left |
|
|
|
| Type of cochlear implant |
1 MPEAK |
2 SPEAK |
3 Clarion S series |
|
|
| Mapping (exposure to sound) |
First time |
year, month, day |
(xx weeks after operation) |
|
|
| The final time |
year, month, day |
(xx weeks after operation) |
|
|
| The number of electrodes available |
Electrodes |
|
|
|
|
| The number of channels available |
Channels |
|
|
|
|
| Reoperation (if performed) |
A.D. year, month, day; xx years and xx months old |
Reason for reoperation |
|
|
|
| Q4 |
Hearing loss before operation |
| Average auditory level (quartering) |
Right xx dB, Left xx dB |
If possible, please attach an audiogram to the final page. Give methods used to record audiogram (COR, Peepshow or Playaudiometry etc.) and date of measurement. |
| Congenital anormalies of ear |
1.Present. If present, please specify. |
2. Absent |
3. Undetermined |
|
|
| Disorders of phonation and speech organs: |
Cleft lip |
1. Present |
2. Absent |
3. Undetermined |
|
| Cleft palate |
1. Present |
2. Absent |
3. Undetermined |
|
| Others |
Name of disease: |
|
|
|
| State of physical development |
Control of the head |
xx years and xx months |
Unclear |
|
|
| Start to walk |
xx years and xx months |
Unclear |
|
|
| Others |
|
|
|
|
| Cause of disorders in the central nervous system |
Intellectual impairment |
1. Present |
2. Possibility of impairment |
3. None |
|
| Autism |
1. Present |
2. Possibility of impairment |
3. None |
|
| Minimal brain damage (MBD) |
1. Present |
2. Possibility of impairment |
3. None |
|
| Concrete symptoms |
| Others |
| Q5 |
History prior to operation |
| Age diagnosed as hearing disorder |
xx years and xx months old |
| Use of hearing aid |
1. Yes |
2. No |
|
|
|
| When hearing aid was first used |
xx years and xx months old |
|
|
|
| Duration of use |
xx years xx months |
|
|
|
| Effect of hearing aid |
( )dB improvement as measured by audiogram |
| Presence or absence of effect in actual life |
1. Present |
2. Absent |
3. Neither |
|
| Presence or absence of effect on sound threshold level when hearing aid was used, or of effect on speech audiogram |
1. Present |
2. Absent |
3. Neither |
|
| Have received hearing, speech and language training |
1. Yes |
2. No |
|
|
|
| Age started |
xx years and xx months old |
| Age completed |
xx years and xx months old |
| Contents and achievements |
Please comment freely. |
| Have received letter training (including finger writing) |
1. Yes |
2. No |
|
|
|
| Age started |
xx years and xx months old |
| Age completed |
xx years and xx months old |
| Contents and achievements |
Please comment freely. |
| Have received sign-language training |
1. Yes |
2. No |
|
|
|
| Type of training |
1. Sign language |
2. Cued speech |
3. Gesture |
4. Other |
| Age started |
xx years and xx months old |
| Age completed |
xx years and xx months old |
| Contents and achievements |
Please comment freely. |
