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Audiometric Tests

TINNITUS DATA REGISTRY - AUDIOMETRIC TESTS
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___ AUDIOMETRIC TESTS RELIABILITY 0 = No data 1 = Good 2 = Fair 3 = Poor 8 = Other, see comments
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___ ___ ___ mm dd yy 1. AUDIOGRAM TEST DATE
___ 2. EXAMINER use examiner codes
___ 3. AUDIOMETER LOCATION Use code 88 for "other" audiometer location and code in General Comment Field 0 = no data 1 = Tinnitus Clinic 2 = Rheumatology 3 = Nephrology 4 = PCHS 5 = Kaiser 6 = VA Audiology 7 = ENT Clinic 66 = more than 1 location 77 = other, no comment 88 = other, see comments
___ 4. AUDIOMETER Use code 8 for "other" audiometer and code in General Comment Field 0 = no data 1 = MA - 32 2 = GS 1704 3 = GS 1701 4 = GSI 10 6 = more than 1 audiometer 7 = other, no comment 8 = other, see comments
___ 5a. PRIOR AUDIOGRAMS IN PATIENT FILE
___ 5b. PRIOR AUDIOGRAMS NOT IN PATIENT FILE 0 = no data 1 = no 2 = yes 8 = other, see comments
6. PURE TONE THRESHOLDS leave blank if no data / not applicable dB HL: 000 - 110; 130 = at limits of equipment 250 500 1000 2000 3000 4000 6000 8000
A. RIGHT EAR, dB HL _____ _____ ____ ____ ____ ____ ____ ____
B. LEFT EAR, dB HL _____ _____ ____ ____ ____ ____ ____ ____
7. BONE CONDUCTION use codes for pure tone thresholds
A. RIGHT EAR, dB HL _____ _____ ____ ____ ____ ____
B. LEFT EAR, dB HL _____ _____ ____ ____ ____ ____
8. SPEECH RECEPTION THRESHOLD (SRT) use codes for pure tone thresholds
A. RIGHT EAR ________ dBHL
B. LEFT EAR ________ dBHL
9. SPEECH DISCRIMINATION
A. RIGHT EAR ________ % at ________ dBHL
B. LEFT EAR ________ % at ________ dBHL
___ EXAMINER: CONDUCTIVE HEARING LOSS? 0 = no data 1 = not conductive 2 = conductive RE 3 = conductive LE 4 = conductive BE 6 = unsure 8 = other, see comments
10. LOUDNESS DISCOMFORT LEVEL Reference: 0 = no data 1 = SPL 2 = HL
A. RIGHT EAR ________ dB ____ Reference
B. LEFT EAR ________ dB ____ Reference
11. TYMPANOGRAM 0 = no data 1 = type A 2 = type As 3 = type Ad 4 = type B 5 = type C 7 = other, no comment 8 = other, see comments
___ A. RIGHT EAR
___ B. LEFT EAR
___ ___ ___ mm dd yy C. TYMPANOGRAM DATE leave blank if date not available
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AUDIOMETRICS - GENERAL COMMENT FIELD COMMENTS:______________________________________________________________________ ===============================================================================