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
AUDIOMETRICS - GENERAL COMMENT FIELD
COMMENTS:______________________________________________________________________
===============================================================================