Ladge Speech & Hearing Center
(516) 299-2436
Client:
Address:
DOB:
DOE:
Age:
(date of birth)
(date of entry)
(years)
Phone:
Referred by:
AUDIOLOGICAL EVALUATION
Background Information:
Includes reason for referral and source of referral.
Pertinent history:
For children: Includes Information concerning birth history, physical
development, childhood diseases, history of ear infections, family
history of hearing impairment, previous hearing evaluations, etc.
For adults: Includes any history of middle ear problems, family
history of hearing impairment, physical problems, significant illness,
clients own assessment of hearing problems, previous hearing
evaluations, noted length of hearing difficulty, possible etiology, etc.
Test Results:
Describe audiological tests which were conducted: Pure tone audiometry,
speech audiometry, tone decay screening, etc. Describe how test results were
obtained: Routine audiometry, play audiometry, COR, BOA, etc.
Acoustic Immittance:
Describe how test results were obtained: Screening tympanometry for young
children, clinical impedance audiometry for older children and adults. Describe the
test results that were obtained.
......................................................................................................
Impressions/Recommendations:
Test results are interpreted regarding the type of hearing loss (WNL, SNHL,
CONHL, MXHL). Describe degree and pattern of hearing loss, possible etiology,
need for amplification or not, referral for medical evaluation, need for further
diagnostic audiological evaluations (BSER, ENG, etc.), possible need for aural
rehabilitation. Client and of family members are provided counseling concerning the
above and recommendations are made.
_____________________
Examiner
Date of Report Written xx/xx/xx
forms/audiol/eval