Audiometric Evaluation Summary Form
Document key findings and recommendations from a comprehensive hearing test evaluation.
Patient Full Name
*
First Name
Last Name
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Evaluator Name
*
Type of Hearing Test
*
Pure Tone Audiometry
Speech Audiometry
Tympanometry
Other
Air Conduction Thresholds (dB HL)
*
Rows
Right Ear
Left Ear
250 Hz
500 Hz
1000 Hz
2000 Hz
4000 Hz
8000 Hz
Bone Conduction Thresholds (dB HL)
Rows
Right Ear
Left Ear
500 Hz
1000 Hz
2000 Hz
4000 Hz
Speech Discrimination Score
Rows
Right Ear (%)
Left Ear (%)
Score
Tympanometry Result
Type A (Normal)
Type B (Flat)
Type C (Negative Pressure)
Not Performed
Overall Hearing Loss Severity
*
Normal
1
2
3
4
Profound
5
1 is Normal, 5 is Profound
Recommendations / Follow-up
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