Audiology Examination Form
Please complete this form with accurate information to assist in your audiology assessment.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Reason for Visit
*
Please Select
Routine hearing check
Hearing loss
Tinnitus (ringing in ears)
Dizziness/Vertigo
Ear pain/discomfort
Other
Please describe your main hearing-related symptoms (duration, severity, side, etc.)
*
Do you have a family history of hearing loss?
*
Yes
No
Not sure
Have you been exposed to loud noises regularly (work, hobbies, etc.)?
*
Yes
No
Current Medications (if any)
Relevant Medical History (ear infections, surgeries, chronic diseases, etc.)
Audiological Assessment Results
Rows
Left Ear
Right Ear
Pure Tone Audiometry
Speech Audiometry
Tympanometry
Acoustic Reflexes
Additional Notes or Observations
Signature (Patient or Guardian)
*
Submit Examination
Submit Examination
Should be Empty: