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Hearing Evaluation
Date (e.g. January 1, 20xx)
Patient:
Date of Birth:
Address:
Phone:
Referral Source:
Clinical Faculty:
Diagnosis Code:
Title (Ms, Mrs, Mr., Dr) First Last
01/02/20XX Chronological Age: 63 years
XXXXX Best Street Best Town, VT XXXXX
(XXX) XXX-XXXX
Self
Dinah Smith, MA, CCC-A
389.17: Sensorineural hearing loss, unilateral
389.21: Mixed hearing loss, unilateral
History:
XXXX XXXXX was seen today at the Eleanor M. Luse Center for hearing re-evaluation. Mr. XXXX
made this appointment because his current and back-up hearing aids for his right ear are ready for
replacement. He has been using amplification in his right ear for many years, and he has noted
increasing difficulty in all listening situations, not attributable to increasing hearing loss but poor
function of both his hearing aids. Conversation and birdsong are important listening situations. He
enjoys good health, hiking, tennis, skiing, and travel with his wife. He is actively employed, and he
has a strong involvement in his local community.
Mr. XXXXX described bilateral tinnitus (ringing in his ears) which is not noticeable most of the time.
He denied dizziness or unsteadiness. Mr. XXXXX does not have a family history of hearing loss and
no history of noise exposure. At present, he uses his oldest hearing aid, Starkey Intra canal style
hearing aid, in his right ear; it produces feedback in conjunction with any loud noise. Vision in his
left eye still has not recovered since it was affected by shingles five years ago.
Description of Service & findings:
Otoscopic visualization revealed clear ear canals and tympanic membranes. All landmarks were
identified and the tympanic membranes were healthy in appearance.
Pure tone air and bone conduction thresholds were assessed using pulsed tones and a typical hand
raising response method. In the right ear, testing identified a moderate to severe mixed type
hearing loss. In the left ear, hearing was normal through 1500 Hz with a mild loss at 2000 Hz. In
the higher frequencies, Mr. XXXXX has a severe to profound sensorineural hearing loss. Speech
reception thresholds were in agreement with pure tone air conduction thresholds and supported
the reliability of the tests. Word recognition ability was assessed at presentation levels louder than
typical speech and found to be ‘excellent.’ For specific audiometric data, please refer to the
attached audiogram.
Clinical Assessment:
Mr. XXXXX has a significant bilateral hearing loss. When he is in less than ideal listening conditions,
his difficulty will increase considerably, and he will need to modify his environment and his
position to the speaker to increase his access to speech. In addition, reduction of noise levels in the
room when possible, decreasing the distance between himself and the person speaking, and
utilizing visual cues will all improve his ability to understand.
Mr. XXXXX is a candidate for a binaural hearing aid fitting. Oticon Ino Pro Receiver in the Ear
hearing aids were selected, and earmold impressions made today.
Plan:
1. Mr. XXXXX has appointments for hearing aid fitting XXXXX XX, 2011 at 11 a.m. and follow-up
XXXXX XX, 2011 at 2:00 p.m.
2. Medical clearance for this hearing aid fitting will be requested from Mr. XXXXX’s physician.
Dinah K. Smith, CCC-A
Clinical Associate Professor
Board Certified in Audiology
cc:
Mr. XXXXX
Dr. Good Doctor
XXXXX Any Street
Any Town, VT XXXXX
Record of Audiological Evaluation
University of Vermont - Eleanor M. Luse Center for Communication: Speech, Language & Hearing
Patient Name:
XXXXXXX
Birth Date: XXXXXXX
Examiner:
Dinah Smith, MA, CCC-A
Reliability: Excellent
Test Date: XXXXXXXX
Audiometer: GSI 61
Pure-Tone Audiometry
Supra-aural
Inserts
Right Ear
x
□
Hz 250
A/C
45
45
40
A/C Masked
Mask Level
B/C
250
500
55
45
10
5
5
15
45
B/C Masked
Mask Level
Left Ear
500 1000 1500 2000 3000 4000 6000 8000
45
45
35
0
15
55
50
65
30
35
70
70
55
1000 1500 2000 3000 4000 6000 8000
5
15
30
70
90
90
90
20
25
100
80
85
75
50
90
Speech Audiometry
SRT
50
45
80
Masking
Level
40
96%
60
13.3
10
x
Right
MLV
Masking
Level
250
MCL UCL
Speech
In
Noise
Right
-10
0
10
20
30
40
50
60
Left Ear
No Response =
R
SNR
Loss
□
X
↓
Sound Field =
HL
>
Aided =
]
A
UNIT:
3.0
70
2.0
1.5
1.0
.5
0
-300 -200 -100
0
+100
Air Pressure (daPa)
90
Right
Ear Canal Vol.
110
120
Compliance
Pressure
Right Ear
Air
Air
Masked
Bone
Bone
Masked
O
Δ
<
[
Azimuth
HL
S
Tympanometry
80
100
BIN
HL
SOUNDFIELD
Pure-Tone Audiogram
Frequency (Hz)
1500
3000
6000
500 1000
2000
4000
8000
Left
SNR
Loss
□ QuickSIN
□ BKB-SIN
75
100%
55
Left
125
Hearing Threshold Level in dB (ANSI 89)
PTA
Compliance (cm3)
Recorded
□
Ear
HL
HL
PB%
PB%
Left
L