Free 35055.pdf - Indiana

REPORT OF HEARING AND EAR ASSESSMENT
State Form 35055 (R6 / 9-96) / VRS 2051

VOCATIONAL REHABILITATION

TO EXAMINER(S): Please send completed report to: PART I (to be completed by counselor or applicant)
The information recorded on this form by the VR counselor is to provide the examiner with pertinent background to assist in evaluating the extent of hearing impairment of this referral. It is not to be used for any other purpose.

GENERAL INFORMATION
Name of applicant (last, first, middle initial) Home address (number and street, city, state, ZIP code) Telephone number (home / business including area code) Purpose of examination: Date of birth Current occupation:

CASE HISTORY
Is the applicant experiencing any of the following conditions? (medical or other evidence attached - check 3 those that apply) Visible congenital or traumatic deformity of the ear. History of active drainage from the ear within the previous 90 days. History of sudden or rapidly progressive hearing loss within the last 90 days. Acute or chronic dizziness. Unilateral hearing loss of sudden or recent onset within the previous 90 days. Continuous head noise or ringing in the ears (tinnitus). Cerumen accumulation (ear wax) or foreign body in the ear canal. Is there any remarkable ear pathology? (specify treatment and / or surgery - give types and dates) Is the applicant under any medication? Yes No If yes, specify the medication and the reason for which it is being used: What is the cause of hearing loss and when did it take place? (This information is to be provided if the applicant is able to answer this question.) Is the applicant using a hearing aid? Yes No If yes, specify in what situations the hearing aid is being used: Is the applicant having difficulty utilizing a hearing aid? Yes No If yes, specify what reason(s): Is there a family history of hearing impairment or deafness? If yes, what relation(s): Yes No What is the applicant's preferred mode of communication? Discriminating Speech Through a Hearing Aid Sign Language Speechreading Paper and Pencil Braille Tactile Sign Page 1

PART II (To be completed by examiner) HEARING SCREENING (Administered at 20 dB HL) Check (4) all those heard. Right Left
Signature of examiner Date

500 Hz

1000 Hz

2000 Hz

4000 Hz

IF THERE IS A CHECK ( ) IN ALL EIGHT (8) BOXES, DO NOT CONTINUE!

PART III (to be completed by physician) DIAGNOSIS
1. Type of hearing impairment: Sensori-neural 2. Pathology of hearing loss: Conductive Mixed Central

3. Characteristics of hearing impairment: (check 3 those that apply) Stable Fluctuant Improving Slowly Progressive Rapidly Progressive Why? Why?

PROGNOSIS AND RECOMMENDATIONS
1. Prognosis as to receptivity of hearing impairment to treatment:

2. Treatment recommended - medical, surgery, or other therapy:

3. New hearing aid(s) recommended? Yes No If so, describe characteristics of amplification:

Right Ear

Left Ear

4. Are you aware of any hearing-related conditions (such as Meniere's Disease, Tinnitus, Recruitment, etc.) which would restrict the type of work activity performed by this individual? Yes No If so, please specify condition and related restriction:

Place: Date (month, day, year)

Signature of Physician Title

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PART IV (To be completed by examiner) AUDIOMETRIC EXAMINATION
Instrument used: Please enter the appropriate symbol for the right ear in red; the left ear in blue. Please indicate: 125 Aided Score and 250 500 Unaided Score 1000 2000 4000 8000 AC Unmasked AC Masked BC Mastoid Unmasked BC Mastoid Masked BC Forehead Masked

AUDIOGRAM KEY
Right Left

X

H E A R I N G L E V E L I N D E C I B E L S

0 10 20 30 40 50 60 70 80 90 100 110 FREQUENCY IN HERTZ (Hz) PURE TONE AVERAGES EAR RIGHT LEFT Three Frequencies 500, Four Frequencies 500, 1000, and 2000 Hz 1000, 2000 and 4000 Hz dB dB dB dB

0 10 20 30 40 50 60 70 80 90 100 110

BOTH
BC Forehead Unmasked Sound Field

S

EXAMPLES OF NO RESPONSE SYMBOLS

SPEECH AUDIOMETRY Speech Reception Threshold (SRT) dB dB

SPEECH AUDIOMETRY Discrimination score to be obtained at Maximum Comfort Discrimination score to be obtained at 50 dB Hearing Level. Level (MCL) in Quiet. EAR RIGHT LEFT SOUND FIELD Speech Discrimination Scores Quiet % at 50 dB HL Quiet % at 50 dB HL Noise at 0 dB S/N % at 50 dB HL EAR RIGHT LEFT Speech Discrimination Scores (To be administered in Quiet only) MCL dB MCL dB %

%

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Special tests:

Additional comments:

Current aid in: Right ear Satisfactory? Yes Can it be repaired? Yes No Signature of physician or audiologist Date Title No

Current aid in: Left ear Satisfactory? Yes Can it be repaired? Yes No No

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