Speech Understanding Assessment
Frequency Weighted Word Lists
bow
pull
pool
blow
blue
no
wool
noon
bone
broom
prune
Low-Mid
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pope
pole
bowl
room
burn
low
loop
loom
lop
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blood
book
up
boat
pop
numb
bump
ball
bone
pump
mow
Mid-High
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tell
hit
tie
lie
hide
hay
light
isle
high
it
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OUR INQUIRY, OBSERVATION AND HEARING TEST RESULTS FOR:
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40 FT.
gum
law
bum
mop
comb
good
palm
knock
mob
pup
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itch
see
she
ease
each
ace
eyes
ice
is
thigh
teeth
this
sheath
seize
shy
cheese
chase
sight
cease
say
City _______________________________________________________________
5 FT.
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1. RAISE
2. PAGE
3. CHALK
4. LAUD
5. DEATH
6. THIRD
7. BEAN
8. SIZE
9. MET
10. JAR
11. HURL
12. WEEK
13. CHOICE
14. GAP
15. MODE
16. BOAT
17. TOUGH
18. DIME
19. WHIP
20. SURE
21. DOOR
22. SHOUT
23. MOON
24. NAG
25. LIMB
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1. GIN
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2. PICK
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3. PIKE
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4. SHACK
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5. DAB
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6. TURN
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7. KEEP
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8. TOOL
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9. BITE
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10. JUICE
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11. TON
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12. FAIL
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13. MERGE ___
14. HUSH
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15. MILL
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16. BOUGHT ___
17. DEAD
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18. FAR
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19. THOUGHT ___
20. LEARN
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21. LIVE
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22. ROOM
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23. BOOK
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24. YOUNG ___
25. WHITE
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1. PAD
2. MATCH
3. DEEP
4. CHIEF
5. GAZE
6. ROT
7. HAZE
8. CALM
9. SOUTH
10. NICE
11. CHAIR
12. SHAWL
13. SAID
14. GOAL
15. SOAP
16. WAG
17. KEG
18. WITCH
19. LOAF
20. READ
21. HATE
22. RAIN
23. NUMB
24. VOICE
25. LORE
EVALUATION RESULTS
Recommendations:
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Check one:
Insurance Carrier ___________________________________________________
20 FT.
Marital Status
30 FT.
Single
Married
Widowed
Present
I.D. No./Policy No. ______________________________________
Name of Spouse _________________________________________________________
Name of Observing Party ____________________________________________
40 FT.
Relationship ___________________________________________
Name of Family Physician _____________________________________________________________________________________________________
then
else
cap
thin carve
Yes
Permission to release a copy of test information to physician?
No
chew twins deaf ache bathe
How did you hear about us?
Test with loss
Test no loss
Medical referral
Right Hearing Instrument ____________________________________________ Comments: ____________________________________________________
Left Hearing Instrument______________________________________________
Past
Occupation _________________________________________________________________________________
1.Let’s get a cup of coffee.
2.I hate driving at night.
3.Believe me!
4.Let’s get out of here before it’s too late.
5.How do you know?
6.Children like candy.
7.You can catch the bus across the street.
8.I’ll think it over.
9.How do you spell your name?
10. Stop fooling around.
11. They’re not listed in the new phone book.
12. Mother cut the birthday cake.
13. School finished early today.
14. The bath towel was wet.
15. The dog came back.
16. The shirts are hanging in the closet.
17. The train stops at the station.
18. The cat is sitting on the bed.
19. They are buying some bread.
20. He played with his train.
21. A mouse ran down the hole.
22. He cut his finger.
23. Snow falls at Christmas.
24. Milk comes in a carton.
25. A boy fell from the window.
1. KNOCK
2. KITE
3. TAKE
4. KEEN
5. PUFF
6. HASH
7. TIP
8. POOL
9. BURN
10. SUB
11. FAT
12. YES
13. FALL
14. WHICH
15. SELL
16. KING
17. LOT
18. RAID
19. VINE
20. JAIL
21. REACH
22. RAG
23. HOME
24. GOOSE
25. LOVE
State ___________________ Zip __________________________
Phone _____________________________________________________________ E-mail __________________________________________________
Everyday Speech Sentences
Form D
Social Security Number _________________________________
Address ____________________________________________________________________________________________________________________
NU #6 half-lists, Forms A, B, C, D, arranged with the 10 most difficult words listed first.
Form C
Date of Birth _____________________
10 FT.
Form A
Form B
Female
Gender
10 FT.
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Male
Today’s Date _________________
20 FT.
5 FT.
High
at
tale
tear
tire
tide
tile
till
kit
at
ledge
Patient’s Name _______________________________________________________________________________
30 FT.
___________________________________________________
Park Place Hearing Center • 696 Petaluma Boulevard North • Petaluma, CA 94952 • (707) 763-3161 • www.parkplacehearing.net
© 2016 Starkey. All Rights Reserved. 46397-16_6/16
Mail
Phone
Newspaper
Yellow Pages
Television
Web
Physician
Referral ___________________________
Hearing Health History
Do you have any allergies?
Yes
No If yes, please list ___________________________________________________________
Are you an insulin-dependent diabetic?
Yes
No
Are you currently taking medication?
Yes
No If yes, please list ___________________________________________________________
______________________________________________________________________________________________________________________________
Do you have arthritis?
Yes
No
Do you have any ringing in your ear(s)?
Yes
No If yes, which ear? __________________________________________________________
Have you previously had a hearing test?
Yes
No If yes, by whom? ________________________________________ Date _____________
Have you received any medical or surgical treatment for a hearing loss?
Yes
No
If yes, when? _____________ Physician/ENT: _____________________________________________________ Phone _________________________
Address __________________________________________ City _____________________________ State ___________ Zip _____________________
Additional information about treatment: __________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Amplification History
Are you a current hearing aid wearer?
Yes
No Type __________________________________ Ear fitted:
Both
Left
Right
If yes, and you could improve something about your current hearing instruments, what would that be?____________________________________
______________________________________________________________________________________________________________________________
Do you know anyone who wears hearing aids?
Yes
No
If yes, who?_________________________________________________________
Hearing Care Professional____________________________________________
License No. ______________________________________________
Park Place Hearing Center • 696 Petaluma Boulevard North • Petaluma, CA 94952 • (707) 763-3161 • www.parkplacehearing.net
NAME:
Low
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HEARING HEALTH REPORT
Hearing Distance Assessment
Patient’s Test Results
No
• Have you experienced any acute or chronic dizziness? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
• Is there a unilateral hearing loss of sudden or recent onset within the previous 90 days? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
• Have you experienced any pain or discomfort? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
• Audiometric air-bone gap equal to, or greater than, 15 dB at 500 Hz, 1000 Hz and 2000 Hz? . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
80
00
Yes
60
00
• Any history of sudden or rapidly progressive hearing loss within the previous 90 days? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
40
00
No
30
00
Yes
20
00
• Any history of, or active drainage from, the ear within the previous 90 days? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
-10
15
00
No
10
00
Yes
75
0
• Visible evidence of significant cerumen accumulation or a foreign body in the ear canal? . . . . . . . . . . . . . . . . . . . . . . . . . . .
Frequency in Hz
50
0
No
25
0
Yes
12
5
• Visible congenital or traumatic deformity of the ear? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
NORMAL
OK
FDA Questions
10
20
SLIGHT
30
MILD
If the answer is “Yes” to any of these questions, patient must be referred to a physician or ear specialist prior to a hearing instrument fitting.
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______________________________________________________________________________________________________________________________
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AMPLIFICATION RECOMMENDED
______________________________________________________________________________________________________________________________
Hearing Level in dB (ANSI 1969)
Intake Notes
40
MODERATE
50
60
MODERATELY
SEVERE
70
SEVERE
80
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
PROFOUND
90
PROFOUND
100
110
______________________________________________________________________________________________________________________________
22%
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
22%
56%
IMPORTANCE TO SPEECH INTELLIGIBILITY
WORD RECOGNITION TEST RESULTS
EAR
______________________________________________________________________________________________________________________________
UCL (HTL)
MCL (HTL)
SRT (HTL)
% CORRECT
PRESENT LEVEL
Ambient Noise Level
RIGHT
(in dB SPL) ________________________
LEFT
______________________________________________________________________________________________________________________________
BINAURAL
L
R
L
R
RESPONSE
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Test Environment
Left Right
NO RESPONSE
Left Right
Left Right
Left Right
Air Conduction Unmasked
Bone Conduction Mastoid Unmasked
Air Conduction Unmasked
Bone Conduction Mastoid Unmasked
Air Conduction Masked
Bone Conduction Mastoid Masked
Air Conduction Masked
Bone Conduction Mastoid Masked
UCL
