Institut für Humangenetik

Universität Göttingen

25.1.2000

Townes-Brocks Syndrome Questionnaire

Please fill out for each affected family member and send back to:
 

Dr. Jürgen Kohlhase, Institute for Human Genetics, Heinrich-Düker-Weg 12,

D-37073 Göttingen, Germany. Fax: +49-551-39-9303. Email: jkohlha@gwdg.de
 

Name of patient:	date of birth:
DNA number:
ethnic origin:
Symptoms/ features:
EARS
malformations:	O yes  (please specify:	O no
Hearing: Audiometry performed:	O yes	O no

Sensorineural hearing loss:	O yes left:	dB,  right:	dB	O no
Conductive hearing loss:	O yes left:	dB,  right:	dB	O no
ANUS
Imperforate anus:	O yes	Grade:		O no
Fistulas:	O yes	O no	other anal anomalies (constipation, raphe):
HANDS
Preaxial Polydactyly:	O yes	O no
Syndactyly:	O yes	Fingers:	O no
Triphalangeal thumbs:	O yes	O no	other hand anomalies (please specify):
Hand X-ray performed:	O yes	O no
FEET
Syndactyly:	O yes Toes:	O no
other feet malformations/ anomalies

KIDNEYS
Ultrasound:	O normal size and structure	O anomalies (please specify):
Urine analysis:	O normal	O pathological (please specify):
Creatinin clearance:	O normal	O pathological (please specify):
Urogenital region:	O normal	O anomalies (please specify):

HEART	O normal	O congenital heart defect	type:
	O cardiac ultrasound not performed

PSYCHOMOTOR DEVELOPMENT
Mental retardation:	O yes, grade:	IQ:	test method:	O no MR
Not assessed:	O yes

                      :        :        :                                    

Other symptoms not listed above (please list all noted abnormalities):
 
 
 
 
 
 

Name of investigator::

Institution:

Address:
 
 
 

Date: