Comprehensive Hearing Evaluation Report (Audiology)

Patient Name: [Patient full name]   DOB: [Date of birth]   MRN: [Medical record number]

Date of Service: [Date of evaluation]   Report Date: [Date report finalized]

Audiologist: [Audiologist name, credentials]

Facility/Location: [Facility or clinic location]

Referral Source: [Referring clinician name, credentials, organization] (If direct access without physician order, document "Direct Access Diagnostic Audiology" and note eligibility basis.)

Reason for Referral: [Reason as provided by referral source or patient-stated if direct access]

Reason for Evaluation

[Patient's chief concern and the clinical question being addressed] (1–3 sentences; use the patient's own words when helpful. Indicate clinical purpose such as rule out middle ear pathology, establish baseline prior to ototoxic medication, monitor known hearing loss, or evaluate candidacy for amplification.)

Case History

(Include relevant domains with bold subheadings. Omit domains not applicable. If history is incomplete, briefly state why.)

• Symptom Characterization: [Onset, duration, progression, laterality, fluctuation, situational difficulty]
• Associated Symptoms: [Tinnitus with laterality and character, otalgia, otorrhea, aural fullness, dizziness/vertigo/imbalance]
• Medical History: [Ear infections, ear surgery, head trauma, ototoxic medication exposure, relevant systemic conditions]
• Noise Exposure: [Occupational, recreational, military; hearing protection use]
• Family History: [Hearing loss in first-degree relatives]
• Amplification History: [Hearing aids, cochlear implants, assistive devices; prior benefit and limitations]
• Prior Testing: [Previous audiology or ENT evaluations with dates and salient results]
• Patient Goals: [Communication priorities and key listening environments]

Otoscopy

(Document findings per ear. If cerumen management performed, document procedure, outcome, and timing relative to testing. If otoscopy not performed, state reason.)

Right Ear: [Canal status, tympanic membrane visualization and notable findings, cerumen management details if performed]

Left Ear: [Canal status, tympanic membrane visualization and notable findings, cerumen management details if performed]

Test Conditions and Reliability

• Transducers: [Insert earphones / supra-aural headphones / bone oscillator / soundfield]
• Test Environment: [Sound booth / alternate setting with any limitations noted]
• Patient Factors: [Cooperation, alertness, response mode, interpreter use, other relevant factors]
• Reliability: [Excellent / Good / Fair / Poor] — [Justification: response consistency, SRT-PTA agreement, repeat threshold variability]
• Protocol Deviations: [Nonstandard frequencies, modified step sizes, incomplete masking, or other deviations] (Include only if applicable.)

Immittance Assessment

(Include this section only if tympanometry and/or acoustic reflexes were performed.)

Tympanometry:

• Right Ear: [Probe tone frequency] [Type/classification] [Peak pressure (daPa)] [Peak admittance/compliance] [Ear canal volume] [Technical limitations if any]
• Left Ear: [Probe tone frequency] [Type/classification] [Peak pressure (daPa)] [Peak admittance/compliance] [Ear canal volume] [Technical limitations if any]

Acoustic Reflexes: [Ipsilateral / contralateral] [Frequencies tested]

• Right Ear: [Thresholds or present / absent / elevated] [Not measurable with reason if applicable]
• Left Ear: [Thresholds or present / absent / elevated] [Not measurable with reason if applicable]

Reflex Decay: [Results and interpretation] (Include only when indicated for retrocochlear concern.)

Pure-Tone Audiometry

Air Conduction: [Frequencies tested, masking used, no-response notations at equipment limits if applicable, extended high-frequency testing if performed]

Bone Conduction: [Frequencies tested, masking details]

Audiogram: [Graphic audiogram and/or tabular threshold data with standard symbols, labeled axes, and test date] (Attach audiogram image. Provide both graphic and tabular formats when feasible for longitudinal comparison.)

Comparison to Prior: [Prior test date(s), summary of clinically meaningful changes such as threshold shifts or new asymmetry, note if results are not directly comparable] (Include only if prior audiograms available.)

Speech Audiometry

Speech Thresholds: [SRT / SDT / SAT] — Right: [Threshold, masking] — Left: [Threshold, masking] [Presentation method if relevant]

Word Recognition: [Materials used] at [Presentation level] — Right: [Score %] — Left: [Score %] [Masking conditions, qualitative observations such as rollover if present]

Speech-in-Noise: [Test used, conditions, score, interpretation] (If patient reports difficulty in noise but test not performed, note rationale and consider recommending at follow-up.)

Additional Testing

(Include only tests that were performed. Omit this entire section if not applicable.)

• Otoacoustic Emissions: [TEOAE / DPOAE] [Pass/refer or amplitude/SNR summary per ear] [Test conditions]
• High-Frequency Audiometry: [Frequencies tested] [Interpretive purpose]
• Other: [Stenger testing, tinnitus characterization, vestibular screening, or other tests with findings]

Results Summary

• Right Ear: [Degree, configuration, type (conductive / sensorineural / mixed), speech results summary]
• Left Ear: [Degree, configuration, type (conductive / sensorineural / mixed), speech results summary]
• Middle Ear Status: [Summary from otoscopy and immittance]
• Validity/Cross-checks: [Test agreement and reliability statement]
• Monitoring Context: [Baseline vs change from prior; clinically significant shifts] (Include only if applicable.)

Interpretation

[Narrative interpretation integrating pure-tone, speech, and immittance findings] (Use qualified language such as "findings consistent with" or "suggestive of" for site-of-lesion impressions. Address significance of asymmetry and whether referral thresholds are met. Relate results to reported functional difficulties. Note limitations such as incomplete testing, reliability concerns, or language barriers. Avoid unqualified medical diagnoses.)

Recommendations

(Number in priority order. Omit categories that do not apply.)

1. Medical Referral: [Urgent / Routine] to [Specialty] for [Rationale: sudden onset, significant asymmetry, unilateral or pulsatile tinnitus, otorrhea, abnormal otoscopy, unexplained conductive component, other red flags]
2. Audiologic Management: [Hearing aid evaluation, reprogramming, assistive listening devices, communication strategies counseling, aural rehabilitation with timeline]
3. Hearing Conservation: [Noise exposure counseling and hearing protection recommendations]
4. Follow-up: [Timeframe for repeat testing and rationale]
5. Additional Testing: [Further audiologic evaluation recommended with rationale]

Counseling Provided: [Type/degree of hearing loss explained, implications for communication, management options discussed, patient questions addressed, patient preference/decision]

(If any expected component could not be completed, document reason above and include plan to complete at follow-up. Attach audiogram and tympanogram printouts when available.)

Audiologist Signature: [Name, credentials, date]