Dr.

Shakuntala Misra National Rehabilitation University, Lucknow

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Mohaan Road, Lucknow - 226 017, Phone (Off.): 8004930056/0522-2999862 Website : http://dsmru.up.nic.in

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:

Right ear Left ear

Otoscopy:

Audiometer:

Right AC Left
Unmasked
Masked

Unmasked no Response
masked no Response

Right BC Left
< Unmasked >
[ Masked ]
< Unmasked no Response >
[ masked no Response ]

Masking Plateau Tuning Fork test result

Frequency ( in Hz) Name of
Right Left
250 500 1000 2000 4000 test
BC Rinne
Weber
AC Big
Responses: Reliable/Fairly reliable/ Not reliable
Test condition: Satisfactory/Not satisfactory/ If any other, specify
Procedure: Standard / Play
1
 Speech Audiometry
Test P.T.A S.A.T S.R.T W.R.S M.C.L U.C.L
Ear (dBHL) (dBHL) (dBHL) (dBHL) (dBHL) (dBHL)

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

Acoustic Reflex Tests

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:

BTE (shell): Right / Left / Both

Body level (complete): Right / Left / Both
CIC (shell): Right / Left / Both
CROS (open): Right / Left

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

(Student Clinician) (Supervisor)