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dl.

A-l:

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FM:FM
Risht Left

Cl:Cochlear Implant
TYMPANOMETRY

Audiogram Dated: 413012012


-10
0 10 20 30

3,

O u**!ut X A rff"o n
I

lmnlml

risht

lefa

u*""Su"o

PC .9 PP -73 pv
S

.9

-185
.9

[ -/

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]
- Soundfield A - Aided Soundfield

1.0

40 50 60 70
80 90 100 110
AC - Air Conduction BC - Bone Conduction

Jrlpe A

SAT
Right Lefl
Sound

-/

MCL
5 0

sFtt

-/ucl-

-/

Recognition Score

OUIET
40dB
100o/o

NOISE
SN
SiN

120

40dB 10004
S/N

Field
SAI Aided Bone SRT SRT List: Pict Cards NU6 Disc. List:

n rapp X nrr-v
[-l rnpp X
Lt
rr'rr-v

NOTE: ANSI 1969 Reference

Hearing Aid: Rt Settings: Serial Number:


Test

n rtuy n vna X standard fJ noa

Reliability:

Good

p'ui.

n popf-

. .:

n Hearing Protection n Re-evaluation n rollowing Medical fl3o ouyt n6Months nlY"a. !2Y"att !3Y.u.t
X
Comments
See APD report.

n I n

vtedical Evaluation
Referral to Deaf/Hard of Hearing Programs Hearing Aid Evaluation

Preferential Classroom Seating with the (right/left) ear toward the source of instruction

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