Pediatric Audiology Evaluation Report (Behavioral Testing)

Pediatric Audiology Evaluation – Behavioral Testing

Patient Name: [Patient full name]    MRN: [Medical record number]    DOB: [DOB]    Chronologic Age: [Age]    Corrected Age: [Corrected age / Not applicable]

Date of Service: [Date]    Facility: [Clinic/site]    Audiologist: [Name, credentials]

Referring Provider: [Name, credentials]    Reason for Referral: [Referral question/chief concern]    Caregiver(s) Present: [Names/relationship]

Preferred Language: [Language]    Interpreter Used: [Yes / No]; [in-person / phone / video / N/A]    Communication Mode(s): [Spoken language / Sign language / Multimodal]

Reason for Evaluation

[Referral question and functional concern prompting evaluation] (1–3 sentences. Include referral reason such as speech-language delay, failed screening, medical risk monitoring, or follow-up. State whether this is an [initial diagnostic / monitoring / re-evaluation] visit.)

Case History

Sources of Information: [Caregiver interview / Chart review / Outside records / School reports]

Auditory and Otologic History: [Newborn hearing screening result with date and source attribution; prior audiology results; history of otitis media and tube placement; current ear symptoms] (If NBHS status is not verified in records, attribute to caregiver report. Use "Unknown" or "Not reported" if unavailable.)

Medical and Perinatal History: [Gestational age; birth history/NICU course; ototoxic medication exposures; infections including CMV status; craniofacial anomalies; known syndromes/genetic findings; relevant neurologic history] (Use "Unknown" or "Not reported" if unavailable.)

Development and Communication History: [Speech-language milestones; current expressive/receptive abilities; therapies; educational placement; IEP/IFSP status; primary language(s) at home; caregiver and school concerns about hearing or listening]

Family History: [Family history of childhood-onset or progressive hearing differences] (Specify relationship and laterality/progression if known.)

Risk Factors Influencing Monitoring:

• NICU stay >5 days: [Yes / No / Unknown] (Include duration if known.)
• CMV: [Congenital / Acquired / Negative / Unknown]
• Aminoglycoside or other ototoxic exposure: [Yes / No / Unknown]
• Meningitis or intracranial infection: [Yes / No / Unknown]
• Other risk factors: [List / None / Unknown]

Pre-Test Observations and Otoscopy

Behavioral Observations: [Child state, attention span, ability to condition to task, tolerance of transducers/equipment, sensory/behavioral factors affecting reliability, reinforcer preferences or aversions]

Otoscopy:

• Right Ear: [Canal status; cerumen; tube presence; tympanic membrane color/landmarks/position] (Descriptive only; do not diagnose.)
• Left Ear: [Canal status; cerumen; tube presence; tympanic membrane color/landmarks/position] (Descriptive only; do not diagnose.)

(If otoscopy not performed, state reason.)

Test Battery and Methods

Test Environment: [Sound-treated booth / Alternative setting] (Describe deviations from standard environment if any.)

Transducers: [Insert earphones / Supra-aural headphones / Soundfield speakers / Bone oscillator]

Stimuli: [Warble tones / Narrowband noise / Pulsed tones / Speech stimuli]

Response Mode: [Head-turn / Conditioned play task / Hand-raise / Button press]

Masking: [Used / Not used / Not possible] (If not possible, briefly explain why and note interpretation limitations.)

Primary Behavioral Method: [VRA / CPA / Conventional]; [Conditioning success and method-specific details]

Reliability: [Good / Fair / Poor]; [Brief justification based on response consistency, false positives, fatigue, and conditioning quality]. Results represent [threshold estimates / minimum response levels (MRLs)].

Cross-Check Measures: [Immittance / OAEs / Not obtained]; [Whether findings converge with behavioral results] (If not obtained, document why and impact on confidence.)

Results

(Organize by ear when ear-specific testing is achieved. If only soundfield testing was possible, label clearly as Soundfield and note that results reflect the better-hearing ear.)

Acoustic Immittance

(Include only if performed.)

• Right Ear: Probe tone: [226 Hz / 1000 Hz]; Tympanogram: [Type]; Peak pressure: [___] daPa; Static admittance: [___] mL; ECV: [___] mL; Width: [___] daPa; Acoustic reflexes: [Ipsi/Contra present/absent/elevated/not tested at specified frequencies].
  Interpretation: [Brief statement consistent with middle ear status without diagnosing pathology.]
• Left Ear: Probe tone: [226 Hz / 1000 Hz]; Tympanogram: [Type]; Peak pressure: [___] daPa; Static admittance: [___] mL; ECV: [___] mL; Width: [___] daPa; Acoustic reflexes: [Ipsi/Contra present/absent/elevated/not tested at specified frequencies].
  Interpretation: [Brief statement consistent with middle ear status without diagnosing pathology.]

Otoacoustic Emissions

(Include only if performed.)

• Right Ear: [DPOAE / TEOAE]; Frequencies tested: [___]; [Present/Absent by frequency band]; [Noise floor issues if any].
  Interpretation: [Statement regarding cochlear outer hair cell function; do not infer specific hearing thresholds.]
• Left Ear: [DPOAE / TEOAE]; Frequencies tested: [___]; [Present/Absent by frequency band]; [Noise floor issues if any].
  Interpretation: [Statement regarding cochlear outer hair cell function; do not infer specific hearing thresholds.]

Behavioral Audiometry

(Indicate whether values are thresholds or MRLs. Include transducer, conduction type, and masking status. If no response obtained at equipment limits, document the lowest level tested.)

• Right Ear (Air Conduction): Transducer: [Insert / Supra-aural]; Masking: [Yes / No].
  250 Hz: [___] dB HL; 500 Hz: [___] dB HL; 1000 Hz: [___] dB HL; 2000 Hz: [___] dB HL; 3000 Hz: [___] dB HL; 4000 Hz: [___] dB HL; 6000 Hz: [___] dB HL; 8000 Hz: [___] dB HL. [Threshold / MRL]
  Frequencies not obtained: [List with reason, or None].
• Right Ear (Bone Conduction): (Include only if performed.) Masking: [Yes / No]. [Frequencies and values as obtained].
• Left Ear (Air Conduction): Transducer: [Insert / Supra-aural]; Masking: [Yes / No].
  250 Hz: [___] dB HL; 500 Hz: [___] dB HL; 1000 Hz: [___] dB HL; 2000 Hz: [___] dB HL; 3000 Hz: [___] dB HL; 4000 Hz: [___] dB HL; 6000 Hz: [___] dB HL; 8000 Hz: [___] dB HL. [Threshold / MRL]
  Frequencies not obtained: [List with reason, or None].
• Left Ear (Bone Conduction): (Include only if performed.) Masking: [Yes / No]. [Frequencies and values as obtained].
• Soundfield: (Include only if ear-specific testing not achieved.)
  250 Hz: [___] dB HL; 500 Hz: [___] dB HL; 1000 Hz: [___] dB HL; 2000 Hz: [___] dB HL; 4000 Hz: [___] dB HL. [Threshold / MRL]
  Note: Results reflect the better-hearing ear and are not ear-specific.

Speech Audiometry

(Include only if performed.)

• [SAT / SRT]: [Ear-specific / Soundfield]; Materials: [___]; Presentation level: [___] dB HL; Result: [___] dB HL.
• Word Recognition: [Open-set / Closed-set]; [Recorded / MLV]; [Ear/condition]; List: [___]; Presentation level: [___] dB HL; Score: [___%].
• (Document developmental limitations affecting testing, if applicable.)

Aided Measures

(Include only if child uses hearing technology and aided testing was performed.)

• Device(s): [Hearing aids / Cochlear implant / Bone conduction device]; Device check: [Pass / Concerns noted]; Caregiver-reported benefit/concerns: [___].
• Aided soundfield thresholds: 250 Hz: [___] dB HL; 500 Hz: [___] dB HL; 1000 Hz: [___] dB HL; 2000 Hz: [___] dB HL; 4000 Hz: [___] dB HL.

Impression

[Plain-language summary of hearing status by ear including degree/configuration when supported by results. Summarize middle ear status and whether it may have influenced behavioral levels. State reliability and limitations, including whether results are thresholds versus MRLs, what testing could not be completed, and remaining uncertainties. Include functional impact relevant to speech-language access, classroom listening, and localization.] (If only soundfield available, explicitly state ear-specific status cannot be determined. Do not infer unilateral normal hearing from soundfield data. Do not state newborn screening outcome unless verified in records. Do not infer permanence if findings suggest a transient conductive component.)

• Right ear: [Summary statement]
• Left ear: [Summary statement]
• Overall impression: [Concise overall statement]
• Confidence level: [High / Moderate / Low] (Based on reliability and cross-check convergence.)

Plan and Recommendations

1. [Medical referral and urgency if indicated] (Include if red flags present: drainage, sudden change, significant asymmetry.)
2. [Audiology follow-up: interval and purpose] (e.g., return in [___] weeks for ear-specific thresholds after middle ear status addressed.)
3. [Early Intervention or school-based referrals] (Include if hearing differences affect access.)
4. [Speech-language evaluation referral] (Include if delays are present or suspected.)
5. [Electrophysiologic evaluation (ABR)] (Consider if behavioral testing was unreliable or incomplete.)
6. [Listening strategies for home/school] (1–2 concrete tips relevant to child's needs.)
7. Results reviewed with caregiver(s); questions answered; written report [provided / offered].

Signature

Audiologist: [Name]    Credentials: [AuD, CCC-A / Other]    Contact: [Phone / Email]

Report Distribution: [Referring provider / PCP / ENT / School or EI team] (List recipients with appropriate authorization.)

Attachments

Audiogram/tympanogram/OAE printouts attached: [Yes / No]. (If not attached, audiometric data are documented in the Results section above.)