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
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1.
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AUDIOGRAM TEST DATE
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2.
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EXAMINER
use examiner codes
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3.
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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
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4.
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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
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5a.
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PRIOR AUDIOGRAMS IN PATIENT FILE
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5b.
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PRIOR AUDIOGRAMS NOT IN PATIENT FILE
0 = no data
1 = no
2 = yes
8 = other, see comments
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6.
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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
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A.
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RIGHT EAR, dB HL _____ _____ ____ ____ ____ ____ ____ ____
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B.
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LEFT EAR, dB HL _____ _____ ____ ____ ____ ____ ____ ____
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7.
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BONE CONDUCTION
use codes for pure tone thresholds
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A.
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RIGHT EAR, dB HL _____ _____ ____ ____ ____ ____
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B.
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LEFT EAR, dB HL _____ _____ ____ ____ ____ ____
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8.
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SPEECH RECEPTION THRESHOLD (SRT)
use codes for pure tone thresholds
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A.
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RIGHT EAR ________ dBHL
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B.
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LEFT EAR ________ dBHL
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9.
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SPEECH DISCRIMINATION
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A.
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RIGHT EAR ________ % at ________ dBHL
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B.
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LEFT EAR ________ % at ________ dBHL
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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
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10.
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LOUDNESS DISCOMFORT LEVEL
Reference:
0 = no data
1 = SPL
2 = HL
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A.
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RIGHT EAR ________ dB ____ Reference
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B.
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LEFT EAR ________ dB ____ Reference
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11.
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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
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A.
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RIGHT EAR
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B.
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LEFT EAR
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mm dd yy
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C.
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TYMPANOGRAM DATE
leave blank if date not available
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AUDIOMETRICS - GENERAL COMMENT FIELD
COMMENTS:______________________________________________________________________
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