Fillable Audiogram Master California State University, Fresno

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Audiogram Master California State University, Fresno

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California State University, Fresno
Speech, Language, & Hearing Clinic
5310 North Campus Drive M/S PH 80 – Fresno, CA 93740-8019
Name: ______________________________________________DOB ____________ Date_________________________
Address:____________________________________________________________________________________________
Referred by:____________________ Audiometer ______________ Reliability___________________________________
Standard Audiometry Play Audiometry VRA

BOA
Inserts Earphones
FREQUENCY IN HERTZ (Hz)
CNT = Could not test
DNT = Did not test
CNE = Could not establish
IMMITTANCE AUDIOMETRY
Remarks:
Recorded Live Voice
Speech Materials: N U 6 Quick-SIN WIPI Other: _______________________________
EAR
PTA
SRT
SAT
Quick-
SIN
Score
Discrimination
Quiet Noise
S/N
HL
Masking
MCL
UCL
Sound Field
SRT
SAT
Discrimination
Quiet Noise
HL
Right %
%
Unaided
%
%
Left
%
%
R
Aided
L
%
%
Recommendations ________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________
Student Clinician Signature
________________________________
Supervising Audiologist Signature
Modality
Air
Unmasked
Masked
Response
R L
O X
No Response
R L
O X
Bone
Unmasked
Masked
< >
[ ]
< >
[ ]
Soundfield
Unaided
Aided
S
A
S
A
Probe
Ear
IMMITTANCE AUDIOMETRY
Resting
Pressure
Ear
Canal
Volume
Peak
Compliance
Reflex Thresholds/Screening
500 1000 2000 4000
Right
Ear
Ipsi.
Contra
(Stim Lt)
Left
Ear
Ipsi/
Contra
(Stim Rt)
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Audiogram Master California State University, Fresno

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Completed 22 May 2020

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