Audiological Evaluation: Dr. Shakuntala Misra National Rehabilitation University, Lucknow
Audiological Evaluation: Dr. Shakuntala Misra National Rehabilitation University, Lucknow
Audiological Evaluation: Dr. Shakuntala Misra National Rehabilitation University, Lucknow
AUDIOLOGICAL EVALUATION
Name: Age/Sex:
Case No.: Date:
Tested by: Supervised by:
Follow up case: Yes/No
Reason for follow up check:
Brief History/Chief complaints:
Audiometer:
Right AC Left
Unmasked
Masked
Unmasked no Response
masked no Response
Right BC Left
< Unmasked >
[ Masked ]
< Unmasked no Response >
[ masked no Response ]
Right
Left
IMMITTANCE AUDIOMETRY
Instrument: Test Mode: Automatic/Manual
Test Right Left
Middle ear pressure
( DaPa)
Static compliance
( cc/ml)
Ear canal volume
(cc/ml)
Tympanogram Type
R L L R
Test Reflex Decay
Freq
Contra lateral Ipsi lateral Contra lateral Ipsi lateral Right Left
in Hz
500
1000
2000
4000
WBN
NBN
INTERPRETATION:
2
Hearing aid used, if any: Working / Not working / Beyond economical repairs
Right:
Left:
EAR MOULD:
RECOMMENDATIONS:
1. E.N.T Consultation
2. Neurological Consultation
3. Pediatric Consultation
4. Care of ears
5. Hearing aid trials / Benefit Trial
6. School Placement / Continue Schooling
7. Issue disability certificate
8. Use of speech reading skills
9. Continue use of hearing aid
10. Follow up - 6 months / 1 year / any other