Get the free Audiometric History Form - readinghealth

Reading Hospital Occupational Health Services AUDIOMETRIC HISTORY Date of Birth: Name: Employer: Do you wear hearing aids? INITIAL HISTORY Today's Date: Yes No Hearing Conservation Training completed?

How to fill out audiometric history form

How to fill out an audiometric history form:

1. Start by providing your personal information, including your full name, date of birth, and contact information.
2. Indicate whether you are a new patient or a returning patient.
3. Specify any relevant medical conditions or medications you are currently taking that may affect your hearing.
4. Describe any previous hearing tests or audiograms you have had, including the dates and results, if applicable.
5. Mention any symptoms or concerns you may have regarding your hearing, such as ringing in the ears or difficulty understanding speech.
6. Provide a brief medical history, including any surgeries or treatments related to your ears or hearing, as well as any family history of hearing loss.
7. If you are currently wearing hearing aids or have used them in the past, indicate the type and model, and whether they were beneficial to you.
8. Lastly, sign and date the form to complete the process of filling it out.

Who needs an audiometric history form:

1. Individuals visiting an audiologist or hearing healthcare professional for the first time typically need to fill out an audiometric history form. This allows the healthcare provider to gather relevant information about the patient's hearing health.
2. Returning patients may also need to complete an audiometric history form if there have been any changes in their medical condition, symptoms, or hearing health since their last visit.
3. The form helps the healthcare provider assess the patient's hearing needs, identify potential risk factors, and determine the appropriate course of action for diagnosis, treatment, or management of hearing issues.

For pdfFiller’s FAQs

What is audiometric history form?

Audiometric history form is a document used to record a person's hearing test results and medical history related to hearing health.

Who is required to file audiometric history form?

Employers who are required to conduct audiometric testing and keep records of employee hearing test results are required to file audiometric history form.

How to fill out audiometric history form?

Audiometric history form should be filled out by providing accurate information about the individual's hearing test results and medical history related to hearing health.

What is the purpose of audiometric history form?

The purpose of audiometric history form is to track and monitor the hearing health of individuals who undergo audiometric testing.

What information must be reported on audiometric history form?

Audiometric history form must include the individual's name, date of birth, test date, test results, and any relevant medical history related to hearing health.

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