Get Hearing: Audiogram Form

Filling out the Hearing: Audiogram Form online can be a straightforward process when you have clear guidance. This guide will provide step-by-step instructions to ensure that you accurately complete the required sections of the form.

Follow the steps to fill out the Hearing: Audiogram Form online

1. Click the ‘Get Form’ button to access the Hearing: Audiogram Form and open it in your preferred online editor.
2. Enter the date of the audiogram in the designated space provided.
3. Fill in the test number assigned to the audiogram.
4. Provide the name of the individual undergoing the hearing test by entering the last name followed by the first name in the appropriate fields.
5. Input the birth date of the individual in the specified format: month/day/year.
6. Select the sex of the individual and specify the grade level in the corresponding fields.
7. Input the name of the parent or guardian and their contact phone number.
8. Complete the address section with the number and street, city, county, and ZIP code.
9. Specify the testing location and the testing agency responsible for the audiogram.
10. In the frequency section, fill in the screening thresholds for both ears across the listed frequencies in Hertz.
11. Provide information about the tester’s name.
12. Indicate the audiometer and its serial number in the designated field.
13. Record the audiogram code for air conduction for both right ear and left ear.
14. Check the quality of the test environment as satisfactory or unsatisfactory.
15. Indicate the reliability of the responses as either reliable or unreliable.
16. If necessary, provide comments in the designated comments section.
17. For referral purposes, check and sign where appropriate based on the minimum criteria for referral.
18. Finally, save your changes, and then you can download, print, or share the completed form as needed.

Complete your Hearing: Audiogram Form online today for a smooth submission process.