[ NDSIP Home ] [ University of Nevada, Reno ] [ College of Education ] [ Contact Us ]

Low-Risk Causes

To return to the Screening Forms Menu please use the "x" on the upper right hand side of this window.

Date: _______________________________________
Name of Child: ______________________________
Birth Date: __________________________________
Completed by: _______________________________

Etiology (cause) of hearing loss/deafness:

Please check, if applies:

_____	conductive loss	_____	scarring of the eardrum
_____	kidney disease	_____	rubella (German measles)
_____	trauma/accident	_____	otitis media (ear infections)
_____	genetic deafness*	_____	ototoxic drug therapy
_____	diabetes	_____	noise induced loss
_____	viral infection	_____	other known syndromes:
_____	Disease (meningitis, mumps, scarlet fever, measles, chicken pox, encephalitis		Please name: ________________________
*The genes for genetic deafness and for Usher syndrome are different. An individual at risk for Usher syndrome will probably not have another family member who is deaf, unless they too have Usher syndrome.

If the hearing loss is a result of any of the conditions listed above, the person is at low risk for Usher syndrome. There is always a small chance that there is a secondary cause of the hearing loss, which may be Usher syndrome, but this is extraordinarily rare. Even if the individual is at low risk for Usher syndrome, the person may suffer a vision loss for other reasons. This risk makes is especially important to have regular, comprehensive eye exams.