Name: Name: Last - First - Middle (Initial) Age Birthday Contact #.

Examiner

Address: Date Tested

Case History:

AUDIOGRAM

PURETONE AVERAGE
RE LE

TYMPANOGRAM
RE LE
V
C
P
W

AIR CONDUCTION
AC 250 500 750 1000 1500 2000 3000 4000 6000 8000
RE
LE
BONE CONDUCTION
BC 500 1000 2000 4000
RE
LE

Freq. Freq. Freq. Freq. Freq. Freq. Freq. Freq. Freq. Freq. Freq. Freq.

L/R L/R L/R L/R L/R L/R L/R LR L/R L/R L/R L/R
AC/BC AC/BC AC/BC AC/BC AC/BC AC/BC AC/BC AC/BC AC/BC AC/BC AC/BC AC/BC
M/T M/T M/T M/T M/T M/T M/T M/T M/T M/T M/T M/T

Speech Speech Word Recognition Score MMAX MMIN MMID

Audiometry Recognition =Best BCTE + 40 PLTE 40 + Mmid= (Mmin
Threshold 5dB Largest ABGNTE + Mmax)/2
RE dBHL PL dBHL
LE dBHL PL dBHL

COMMENTS: