Audiogram

AUDIOGRAM

Date tested: 
Time tested: 
Hours since last unprotected noise exposure^ (hours): 
^There should be 12[+] hours since last unprotected noise exposure.
[+] yes, [-] no

Medical history:
[-] Cold, respiratory infection or ear discharge in the last 2-3 weeks.
[-] Trouble with hearing or with communication.
[-] Uses a hearing aid.
[-] Frequent or persistent tinnitus.
[-] Past history of ear problems (e.g. infections, ear or head injuries, ear surgery, etc.).
[-] Family history of hearing problems, deafness or other ear problems.
[-] Claimed workers' compensation or other compensation for hearing loss.
[-] Exposure to loud noise without hearing protection in the last 16 hours.

Noise exposure history:
[-] Occupational noise exposure.
[-] Non-occupational noise exposure: (e.g. loud music, gunfire).

Comments:

Physical examination:
  External canals: 
    Right:
    [-] dermatitis
    [-] fungal infection
    [-] narrowed
    [-] occluded
    Left:
    [-] dermatitis
    [-] fungal infection
    [-] narrowed
    [-] occluded
  Tympanic membranes: 
    Right:
    [-] not visible
    [-] wet perforation
    [-] dry perforation
    [-] effusion
    Left:
    [-] not visible
    [-] wet perforation
    [-] dry perforation
    [-] effusion

Hearing Thresholds (Air Conduction): 
Tested in audiometry booth (yes/no): 
  Right ear (dBA):
    500 Hz: 
    1000 Hz: 
    1500 Hz: 
    2000 Hz: 
    3000 Hz: 
    4000 Hz: 
    6000 Hz: 
    8000 Hz: 
  Left ear (dBA):
    500 Hz: 
    1000 Hz: 
    1500 Hz: 
    2000 Hz: 
    3000 Hz: 
    4000 Hz: 
    6000 Hz: 
    8000 Hz:

Analysis:
[-] Normal for age.

[-] Mild hearing loss (communication not significantly affected).
[-] Moderate hearing loss (communication possibly affected).
[-] Severe hearing loss (significant communication impairment is likely).

[-] No significant change since the last test
[-] A significant change since last test
[-] No previous test results are available.

[-] Pattern and history analysis suggest noise[-] induced hearing loss.
[-] Pattern and history analysis suggest mixed loss caused by noise exposure and other factors.
[-] Pattern and history analysis suggest presbycusis (age[-] related hearing loss).
[-] Pattern and history analysis consistent with an acute illness.
[-] Pattern and history analysis (cause of hearing loss unclear).

Plan:
[-] Repeat test in 12 months.
[-] Repeat test in 1 month.
[-] ENT specialist review.

Audiogram

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