HEARING TEST REPORT

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1. Name : Mr Mrs Child Miss

2. Age Years

3. Gender : Male Female

4. Mobile Number

5. Landline Number

6. Occupation

7. Address

8. Referral Doctor:

Thank you soo much referring Our clinic.

Doctor Name

9. Audiologist Name :

10. Test Recommended:
PTA
HAT
TYMP
OAE
TRP
SPEECH AUDIOMETRY
Hearing Aid User
Old Patient Referral

11. Otoscopic Examination

Right Ear: Wax NAD Perforation Retraction Visible TM

Left Ear: Wax NAD Perforation Retraction Visible TM

12. Tuning Fork Test RINNE:

Right Ear: +VE -VE NR

Left Ear: +VE -VE NR

WEBER : Centre Right Ear Left Ear Both Ear NR

13. Complaint :

14. Purpose of Visit
Routine Hearing Check up
Problem In understanding Speech
Reduced Hearing
Hard of Hearing
Hearing Aid Fitting

15. Onset of the problem : Sudden Gradual From Birth

16. Ear pain :
Yes No

Right Ear Left Ear Both Ear

17. Ear Discharge :
Yes No

Right Ear Left Ear Both Ear

18. Ear Block :
Yes No

Right Ear Left Ear Both Ear

19. Problem in Understanding Speech :
Yes No

Quiet Place Crowded Place Group Conversation

Right Ear Left Ear Both Ear

20. Exposure to Loud Noise:
Yes No

Specify

21. Dizziness or Balance Problem :
Yes No

How often?

22. Ringing, Buzzing or Roaring Sounds in Your Ears :
Yes No

How frequently?

Tinnitus Matching Test
Yes No

	Noise Type	Frequency	Intensity	Residual Inhibition
Right Ear
Left Ear

23. Family History of Hearing Loss :
Yes No

24. Previous Hearing Test Report :
Yes No

Previous Report Date:

PTA RE:

dBHL / LE:

Report Upload (Max 2MB)

25. Hearing Aid
User Non-Uses

Right Ear Left Ear Both Ear

Model

26. OAE Screening : Show

Right Ear: Pass Refer

Left Ear: Pass Refer

27. Hearing Aid Trial : Show

Questionnaire
1. Do you have difficulty hearing someone who whispers? Yes No 2. Do you ask people to repeat themselves? Yes No 3. Do you have difficulty understanding in a group? Yes No 4. Do you have difficulty understanding the radio or TV? Yes No 5. Do you have difficulty understanding in shop or crowded Places? Yes No

EAR :

MODEL :

Test	Unaided		Aided Response		Aided Response
Test	Unaided		Right Ear		Left Ear
Ling Sounds		06		06		06
Spondic Words		10		10		10
Questions		10		10		10
Speech In Quiet		05		05		05
Speech In Noise		05		05		05

28. Recommendation :
ENT Review Hearing Aid F/UP

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