Patient: Date of Test:

Audiologist:
FREQUENCY IN HERTZ Hz

125 250 500 750 1000 1500 2000 3000 4000 6000 8000
-10
NORMAL
0
Ability to understand speech
10
MILD

HEARING LEVEL IN DECIBELS (ANSI) 1989

20 No significant difficulty with
faint speech
30 MODERATE
40 Difficulty only with faint speech

50 Amplification needed
Frequent difficulty with
60 normal speech

70 SEVERE

Frequent difficulty with loud speech

80
Understand only shouted
90 or amplified speech

PROFOUND
100
May not understand even
110 amplified speech

120 8% 14% 22% 33% 23%

<Value List Missing>
IMPORTANCE OF SPEECH INTELLIGIBILITY

SPEECH RESULTS TYMPANOGRAM pres

sure (mmH2O)
Speech Most Un-
Reception Comfortable Comfortable Word Discrimination .9
Threshold Level Level Discrimination Level
(SRT) (MCL) (UCL) Percentage (dB) .8
.7

Compliance
Right .6
.5
Left .4
Binaural .3
.2
Unaided
Soundfield .1
Aided
Soundfield
0

-300 -200 -100 0 +100 +200

COMMENTS AUDIOGRAM KEY

L R NR L NR R L R NR L NR R
Bone Conduction
Air Conduction X O X O Forehead V V V V
Air Conduction Bone Conduction
Masked Forehead Mask
Threshold of
Bone Conduction > < > < Discomfort Pure

Bone Conduction
Masked ] [ ] [