Get the free Hearing: Audiogram Form

RADIOGRAM State of Illinois Department of Public Health Date Test Number Name (last) (first) Birth date Sex Grade (initial) (month) / (day) / (year) Parent/Guardian Phone () (last) (first) Address

How to fill out hearing audiogram form

How to fill out a hearing audiogram form:

1. Begin by filling out your personal information at the top of the form, including your full name, date of birth, and contact details.
2. Next, provide relevant medical information, such as any pre-existing conditions or medications you are currently taking that may affect your hearing.
3. Indicate the reason for the audiogram, such as if it is for a routine check-up, occupational health assessment, or a specific concern.
4. Fill in the date and time of the audiogram appointment, as well as the name of the healthcare professional who will conduct the test.
5. On the form, there will typically be a section to mark your level of hearing loss or impairment. This is usually done using a chart or graph, which you can fill in based on the results of the audiogram test.
6. Make sure to accurately record the measurements for each ear separately, specifying the frequency and decibel levels for different sounds.
7. The form may also ask for additional information or comments about your hearing, such as if you have any difficulty hearing certain sounds or if you experience tinnitus (ringing in the ears).
8. Finally, review the completed form for accuracy, ensuring that all sections are filled in correctly and legibly before signing and dating it.

Who needs a hearing audiogram form:

1. Individuals experiencing hearing loss or difficulty in hearing may need a hearing audiogram form. This could include people of all ages, from children to adults.
2. Employees or individuals in occupational settings that require regular hearing assessments, such as those working in noisy environments or with heavy machinery, may also require a hearing audiogram form.
3. Students or individuals participating in certain sports or activities where hearing abilities are important, such as musicians or athletes, may be required to undergo regular hearing screenings and therefore need a hearing audiogram form.

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What is hearing audiogram form?

The hearing audiogram form is a document that records the results of a hearing test to assess an individual's hearing abilities.

Who is required to file hearing audiogram form?

Employers are usually required to file hearing audiogram forms for their employees who are exposed to high noise levels at work.

How to fill out hearing audiogram form?

The audiogram form must be filled out by a qualified healthcare professional who administers the hearing test to the individual. The form typically includes the individual's personal information, test results, and any recommendations for further action.

What is the purpose of hearing audiogram form?

The purpose of the hearing audiogram form is to track an individual's hearing abilities over time, monitor any changes in hearing health, and determine if any preventative measures or accommodations are necessary.

What information must be reported on hearing audiogram form?

The hearing audiogram form typically includes the individual's name, date of birth, date of the test, test results (including frequencies and decibel levels), and any recommendations for follow-up care.